Provider Demographics
NPI:1265131577
Name:RAGHUMUDRI, ANANTHA
Entity type:Individual
Prefix:
First Name:ANANTHA
Middle Name:
Last Name:RAGHUMUDRI
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 1:9840 REGATTA LN
Mailing Address - Street 2:
Mailing Address - City:JOHNSTON
Mailing Address - State:IA
Mailing Address - Zip Code:50131-3700
Mailing Address - Country:US
Mailing Address - Phone:515-708-9880
Mailing Address - Fax:
Practice Address - Street 1:1111 9TH ST STE 190
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-2527
Practice Address - Country:US
Practice Address - Phone:515-708-9880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IADDS-10082122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program