Provider Demographics
NPI:1508492901
Name:YERUSU, PRAJNA (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRAJNA
Middle Name:
Last Name:YERUSU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-4059
Mailing Address - Country:US
Mailing Address - Phone:518-452-2121
Mailing Address - Fax:
Practice Address - Street 1:1662 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-4059
Practice Address - Country:US
Practice Address - Phone:518-688-3426
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-17
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0622031223G0001X
MADN18586931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty