Provider Demographics
NPI:1477637296
Name:SITARAM, DIPESH P (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIPESH
Middle Name:P
Last Name:SITARAM
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 1:3780 W JONATHAN MOORE PIKE
Mailing Address - Street 2:#180
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-9430
Mailing Address - Country:US
Mailing Address - Phone:812-342-9666
Mailing Address - Fax:812-342-4434
Practice Address - Street 1:3780 W JONATHAN MOORE PIKE STE 180
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-9430
Practice Address - Country:US
Practice Address - Phone:812-342-9666
Practice Address - Fax:812-342-4434
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2017-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010835A1223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry