Provider Demographics
NPI:1750535613
Name:BOPPANA, DINESH (DMD)
Entity type:Individual
Prefix:
First Name:DINESH
Middle Name:
Last Name:BOPPANA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W PATRICK ST
Mailing Address - Street 2:UNIT N
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703-3902
Mailing Address - Country:US
Mailing Address - Phone:240-457-4246
Mailing Address - Fax:
Practice Address - Street 1:1100 W PATRICK ST
Practice Address - Street 2:UNIT N
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21703-3902
Practice Address - Country:US
Practice Address - Phone:240-457-4246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-05
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14609122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD028083600Medicaid