Provider Demographics
NPI:1851583660
Name:DOMA, ANITHA REDDY (BDS)
Entity Type:Individual
Prefix:MRS
First Name:ANITHA
Middle Name:REDDY
Last Name:DOMA
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 JEFFERSON AVE SE STE 221
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4597
Mailing Address - Country:US
Mailing Address - Phone:616-459-1267
Mailing Address - Fax:616-459-0673
Practice Address - Street 1:260 JEFFERSON AVE SE STE 221
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4597
Practice Address - Country:US
Practice Address - Phone:616-459-1267
Practice Address - Fax:616-459-0673
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010195241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice