Provider Demographics
NPI:1073954657
Name:GENTYALA, BALKRISHNA RAMESH (DMD)
Entity Type:Individual
Prefix:
First Name:BALKRISHNA
Middle Name:RAMESH
Last Name:GENTYALA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:BALKRISHNA
Other - Middle Name:RAMESH
Other - Last Name:GANTYALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1064 MASSACHUSETTS AVE
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-4311
Mailing Address - Country:US
Mailing Address - Phone:781-646-4400
Mailing Address - Fax:
Practice Address - Street 1:1064 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476
Practice Address - Country:US
Practice Address - Phone:781-646-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2018-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18563471223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice