MEDICARE: DR. IVAN SUMITRA 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	1223G0001X	General Practice Dentistry	4040	DC

General Provider Information

NPI Number	:	1578540118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IVAN SUMITRA DDS

Provider Business Mailing Address
First Line	:	11815 CHAPEL WOODS CT
Second Line	:
City	:	CLARKSVILLE
State	:	MD
Zip	:	21029-1117
Country	:	US
Telephone Number	:	301-596-9584
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 RHODE ISLAND AVE NE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20018-2839
Country	:	US
Telephone Number	:	202-526-4618
Fax Number	:	202-526-2627

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

Provider Enumeration Date	:	12/25/2005
Last Update Date	:	07/08/2007

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