Provider Demographics
NPI:1023141462
Name:PRASANNA, ANITHA (DMD)
Entity type:Individual
Prefix:DR
First Name:ANITHA
Middle Name:
Last Name:PRASANNA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:ANITHA
Other - Middle Name:
Other - Last Name:PRASANNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:1490 CHENEY HWY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780
Mailing Address - Country:US
Mailing Address - Phone:321-267-3304
Mailing Address - Fax:321-267-9191
Practice Address - Street 1:1490 CHENEY HWY
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780
Practice Address - Country:US
Practice Address - Phone:321-267-3304
Practice Address - Fax:321-267-9191
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN16818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071202700Medicaid