Provider Demographics
NPI:1265131577
Name:RAGHUMUDRI, ANANTHA L (DMD)
Entity type:Individual
Prefix:
First Name:ANANTHA
Middle Name:L
Last Name:RAGHUMUDRI
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 1:1200 UNIVERSITY AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50314-2355
Mailing Address - Country:US
Mailing Address - Phone:515-248-1447
Mailing Address - Fax:515-248-1440
Practice Address - Street 1:2353 SE 14TH ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50320-1109
Practice Address - Country:US
Practice Address - Phone:515-248-1470
Practice Address - Fax:515-248-1474
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-24
Last Update Date:2025-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADDS-10082122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist