Healthcare Provider Details

I. General information

NPI: 1518511369
Provider Name (Legal Business Name): ANUSHA REDDY ETIKALA BDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DR. ANUSHA REDDY ETIKYALA

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 10/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2611 NE 125TH ST
SEATTLE WA
98125-4373
US

IV. Provider business mailing address

2611 NE 125TH ST
SEATTLE WA
98125-4373
US

V. Phone/Fax

Practice location:
  • Phone: 206-365-5880
  • Fax: 206-365-6412
Mailing address:
  • Phone: 206-365-5880
  • Fax: 206-365-6412

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number60887185
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: