Provider Demographics
NPI:1578540118
Name:SUMITRA, IVAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:
Last Name:SUMITRA
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 1:11815 CHAPEL WOODS CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21029-1117
Mailing Address - Country:US
Mailing Address - Phone:301-596-9584
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:202-526-2627
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC40401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice