Provider Demographics
NPI:1093129355
Name:MADDIPATI, SOUJANYA
Entity Type:Individual
Prefix:
First Name:SOUJANYA
Middle Name:
Last Name:MADDIPATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOUJANYA
Other - Middle Name:
Other - Last Name:KOTTAPALLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11830 CHASE WELLESLEY DR APT 1517
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-7777
Mailing Address - Country:US
Mailing Address - Phone:405-240-6651
Mailing Address - Fax:
Practice Address - Street 1:10527- A GULF FREEWAY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77034
Practice Address - Country:US
Practice Address - Phone:214-460-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-16
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0030074122300000X
TX300741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist