Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 0401008648 | VA |
NPI | 1023232089 |
---|---|
Provider Name | Ruksana Talaksi |
First Address | Manassas, VA 20110-4534 |
Second Address | Manassas, VA 20110-4534 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2007 |
Last Update Date | 08/07/2007 |