Provider Demographics
NPI:1518920909
Name:PANCHUMARTI, ANALA (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANALA
Middle Name:
Last Name:PANCHUMARTI
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 1:4714 N.ARMENIA AVE, SUITE 102
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33603
Mailing Address - Country:US
Mailing Address - Phone:813-876-1200
Mailing Address - Fax:
Practice Address - Street 1:4714 N ARMENIA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33603-2603
Practice Address - Country:US
Practice Address - Phone:813-876-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2012-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 18085122300000X
TX222271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX175189301Medicaid
TX8D7729Medicare PIN
V05935Medicare UPIN