Provider Demographics
NPI:1326772187
Name:DUTTA, MARY (RD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DUTTA
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 PEBBLE BEACH LN
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7108
Mailing Address - Country:US
Mailing Address - Phone:832-691-9906
Mailing Address - Fax:
Practice Address - Street 1:9415 BROADWAY ST STE 121
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8094
Practice Address - Country:US
Practice Address - Phone:832-691-9906
Practice Address - Fax:346-502-3585
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-15
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT87871133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered