Provider Demographics
NPI:1013576735
Name:KONERU, PRATHEEK CHOUDARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PRATHEEK
Middle Name:CHOUDARY
Last Name:KONERU
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 1:7312 HAGEN CT APT 1616
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4044
Mailing Address - Country:US
Mailing Address - Phone:630-881-4745
Mailing Address - Fax:
Practice Address - Street 1:8505 DAVIS LAKE PKWY
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-3415
Practice Address - Country:US
Practice Address - Phone:980-430-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-06
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11436122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist