Provider Demographics
NPI:1386672384
Name:GANGADHAR, SUMANA T (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUMANA
Middle Name:T
Last Name:GANGADHAR
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 1:238 W ALLEGHENY RD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:PA
Mailing Address - Zip Code:15126-9775
Mailing Address - Country:US
Mailing Address - Phone:724-695-8447
Mailing Address - Fax:724-695-4688
Practice Address - Street 1:238 W ALLEGHENY RD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:PA
Practice Address - Zip Code:15126-9775
Practice Address - Country:US
Practice Address - Phone:724-695-8477
Practice Address - Fax:724-695-4688
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031039L1223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PABG6567866OtherDEA NUMBER