Provider Demographics
NPI:1023300241
Name:POTARAJU DENTAL SERVICES
Entity type:Organization
Organization Name:POTARAJU DENTAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SATYA
Authorized Official - Middle Name:
Authorized Official - Last Name:POTARAJU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-268-8794
Mailing Address - Street 1:2671 CLEVELAND AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1647
Mailing Address - Country:US
Mailing Address - Phone:614-268-8794
Mailing Address - Fax:
Practice Address - Street 1:2671 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1647
Practice Address - Country:US
Practice Address - Phone:614-268-8794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-05
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300221941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2578750Medicaid