Provider Demographics
NPI:1578878435
Name:KOTI, SUSMITHA RAO (DDS)
Entity Type:Individual
Prefix:
First Name:SUSMITHA RAO
Middle Name:
Last Name:KOTI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6405
Mailing Address - Country:US
Mailing Address - Phone:678-904-5665
Mailing Address - Fax:
Practice Address - Street 1:1740 W 17TH AVE
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3619
Practice Address - Country:US
Practice Address - Phone:458-210-3543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-16
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX276351223G0001X
GADN0141641223G0001X
ORD113081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice