Provider Demographics
NPI:1821766874
Name:DURGAM, ANITHA
Entity Type:Individual
Prefix:
First Name:ANITHA
Middle Name:
Last Name:DURGAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 1ST ST SE REAR 2
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20003-1890
Mailing Address - Country:US
Mailing Address - Phone:202-863-1600
Mailing Address - Fax:
Practice Address - Street 1:412 1ST ST SE REAR 2
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20003-1890
Practice Address - Country:US
Practice Address - Phone:202-863-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-03
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN200053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist