Provider Demographics
NPI:1083817902
Name:KANAKANALA, ANANDA M
Entity Type:Individual
Prefix:
First Name:ANANDA
Middle Name:M
Last Name:KANAKANALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4042
Mailing Address - Country:US
Mailing Address - Phone:508-559-6699
Mailing Address - Fax:508-559-5073
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4042
Practice Address - Country:US
Practice Address - Phone:508-559-6699
Practice Address - Fax:508-559-1158
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2016-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL13162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist