Provider Demographics
NPI:1790199438
Name:SAMARATUNGA, DIMITRI (DMD)
Entity Type:Individual
Prefix:DR
First Name:DIMITRI
Middle Name:
Last Name:SAMARATUNGA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 WATER ST
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:MA
Mailing Address - Zip Code:01420-5478
Mailing Address - Country:US
Mailing Address - Phone:978-342-8500
Mailing Address - Fax:
Practice Address - Street 1:130 WATER ST
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:MA
Practice Address - Zip Code:01420-5478
Practice Address - Country:US
Practice Address - Phone:978-342-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856608122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice