Provider Demographics
NPI:1427316215
Name:NUTAKKI, ANIL P (DDS)
Entity type:Individual
Prefix:
First Name:ANIL
Middle Name:P
Last Name:NUTAKKI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1840 FOLSOM ST STE 301
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80302-5712
Mailing Address - Country:US
Mailing Address - Phone:303-443-1146
Mailing Address - Fax:
Practice Address - Street 1:1840 FOLSOM ST STE 301
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-5712
Practice Address - Country:US
Practice Address - Phone:303-443-1146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-30
Last Update Date:2016-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2020871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice