Provider Demographics
NPI:1528713518
Name:LAKERIDGESMILES
Entity type:Organization
Organization Name:LAKERIDGESMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MALIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOHLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:703-901-7015
Mailing Address - Street 1:12506 LAKE RIDGE DR STE B
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-2397
Mailing Address - Country:US
Mailing Address - Phone:703-901-7015
Mailing Address - Fax:
Practice Address - Street 1:12506 LAKE RIDGE DR STE B
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2397
Practice Address - Country:US
Practice Address - Phone:703-901-7015
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-17
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental