Provider Demographics
NPI:1487067120
Name:DUTT, PRIYANKA (DDS)
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:DUTT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 OLD WOODS AVE
Mailing Address - Street 2:APT 206
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-1422
Mailing Address - Country:US
Mailing Address - Phone:562-595-2862
Mailing Address - Fax:
Practice Address - Street 1:5002 AIRPORT RD NW # 30
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24012-1607
Practice Address - Country:US
Practice Address - Phone:888-344-3613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-10
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 206841223G0001X
VA04014147331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice