MEDICARE: SITARAM DENTAL LLC

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	261QD0000X	Dental Clinic/Center	12010835A	IN

General Provider Information

NPI Number	:	1902055056
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SITARAM DENTAL LLC

Provider Business Mailing Address
First Line	:	3780 W JONATHAN MOORE PIKE STE 180
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-9430
Country	:	US
Telephone Number	:	317-506-8350
Fax Number	:

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	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DIPESH SITARAM
Credential	:	DDS
Telephone Number	:	317-506-8350

Provider Enumeration Date	:	09/13/2008
Last Update Date	:	11/08/2017

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Directions to “SITARAM DENTAL LLC ” Practice Location

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