Provider Demographics
NPI:1689402877
Name:MARKONDA PATNAIK, VIJAY RAHUL (BDS)
Entity type:Individual
Prefix:
First Name:VIJAY RAHUL
Middle Name:
Last Name:MARKONDA PATNAIK
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 CUNNINGHAM DR STE 100
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-6500
Mailing Address - Country:US
Mailing Address - Phone:973-687-4302
Mailing Address - Fax:
Practice Address - Street 1:2400 CUNNINGHAM DR STE 100
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-6500
Practice Address - Country:US
Practice Address - Phone:973-687-4302
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401419087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist