Provider Demographics
NPI:1366095101
Name:DOMMARAJU, SIRISHA (DMD)
Entity type:Individual
Prefix:
First Name:SIRISHA
Middle Name:
Last Name:DOMMARAJU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 N CLARKSON ST APT 202
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80218-1845
Mailing Address - Country:US
Mailing Address - Phone:630-835-5291
Mailing Address - Fax:
Practice Address - Street 1:14401 E BAYAUD AVE UNIT H
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80012-1416
Practice Address - Country:US
Practice Address - Phone:630-835-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODEN.002040631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice