MEDICARE: DR. ANUSHA REDDY ETIKALA BDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	60887185	WA

General Provider Information

NPI Number	:	1518511369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANUSHA REDDY ETIKALA BDS, MS

Provider Business Mailing Address
First Line	:	2611 NE 125TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-4373
Country	:	US
Telephone Number	:	206-365-5880
Fax Number	:	206-365-6412

Provider Business Practice Location Address
First Line	:	2611 NE 125TH ST
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98125-4373
Country	:	US
Telephone Number	:	206-365-5880
Fax Number	:	206-365-6412

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2019
Last Update Date	:	10/17/2019

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