Provider Demographics
NPI:1114059094
Name:TALLA, DURGA (DDS)
Entity Type:Individual
Prefix:
First Name:DURGA
Middle Name:
Last Name:TALLA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19054-3901
Mailing Address - Country:US
Mailing Address - Phone:215-943-0213
Mailing Address - Fax:
Practice Address - Street 1:23204 CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7902
Practice Address - Country:US
Practice Address - Phone:215-752-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95341223G0001X
PADS0375901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02558309Medicaid