MEDICARE: DR. DIPESH P SITARAM DDS

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	1223P0221X	Pediatric Dentistry	12010835A	IN
2	1223G0001X	General Practice Dentistry	12010835A	IN

General Provider Information

NPI Number	:	1477637296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DIPESH P SITARAM DDS

Provider Business Mailing Address
First Line	:	3780 W JONATHAN MOORE PIKE
Second Line	:	#180
City	:	COLUMBUS
State	:	IN
Zip	:	47201-9430
Country	:	US
Telephone Number	:	812-342-9666
Fax Number	:	812-342-4434

Provider Business Practice Location Address
First Line	:	3780 W JONATHAN MOORE PIKE STE 180
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-9430
Country	:	US
Telephone Number	:	812-342-9666
Fax Number	:	812-342-4434

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

Provider Enumeration Date	:	10/25/2006
Last Update Date	:	06/19/2017

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