Provider Demographics
NPI:1073124152
Name:PURI, DIVYA (DMD)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:PURI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14915 MEANDERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2218
Mailing Address - Country:US
Mailing Address - Phone:301-792-1067
Mailing Address - Fax:
Practice Address - Street 1:10630 LITTLE PATUXENT PKWY STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-6210
Practice Address - Country:US
Practice Address - Phone:410-346-2350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD170461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty