Provider Demographics
NPI:1346467255
Name:BELLAMY, DEITRA
Entity Type:Individual
Prefix:DR
First Name:DEITRA
Middle Name:
Last Name:BELLAMY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 ARCADE UNIT 198747
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37219-1994
Mailing Address - Country:US
Mailing Address - Phone:615-750-0337
Mailing Address - Fax:
Practice Address - Street 1:6105 HARFORD RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21214-1312
Practice Address - Country:US
Practice Address - Phone:410-254-5437
Practice Address - Fax:410-254-5310
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD133621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice