Provider Demographics
NPI:1073910113
Name:KETEPALLE, SARITHA (DDS)
Entity Type:Individual
Prefix:
First Name:SARITHA
Middle Name:
Last Name:KETEPALLE
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 1:3001 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4601
Mailing Address - Country:US
Mailing Address - Phone:415-347-6515
Mailing Address - Fax:
Practice Address - Street 1:3001 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4601
Practice Address - Country:US
Practice Address - Phone:415-347-6515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-03
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11300122300000X, 1223G0001X
NY057448122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist