Provider Demographics
NPI:1417358722
Name:DR IVAN SUMITRA DDS
Entity Type:Organization
Organization Name:DR IVAN SUMITRA DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMITRA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:202-526-4618
Mailing Address - Street 1:2430 RHODE ISLAND AVE NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2839
Mailing Address - Country:US
Mailing Address - Phone:202-526-4618
Mailing Address - Fax:
Practice Address - Street 1:2430 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2839
Practice Address - Country:US
Practice Address - Phone:202-526-4618
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-07
Last Update Date:2014-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC4040261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental