Healthcare Provider Details

I. General information

NPI: 1578540118
Provider Name (Legal Business Name): IVAN SUMITRA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/25/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2430 RHODE ISLAND AVE NE
WASHINGTON DC
20018-2839
US

IV. Provider business mailing address

11815 CHAPEL WOODS CT
CLARKSVILLE MD
21029-1117
US

V. Phone/Fax

Practice location:
  • Phone: 202-526-4618
  • Fax: 202-526-2627
Mailing address:
  • Phone: 301-596-9584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4040
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: