Healthcare Provider Details

I. General information

NPI: 1053157107
Provider Name (Legal Business Name): AMULYA KOTHA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

327 S AVALON PARK BLVD
ORLANDO FL
32828-6781
US

IV. Provider business mailing address

43178 ASHLEY GREEN DR
ASHBURN VA
20148-7045
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN29115
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: