Provider Demographics
NPI:1164287710
Name:DIVYA PEDDIREDDY DENTAL CORPORATION
Entity Type:Organization
Organization Name:DIVYA PEDDIREDDY DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIVYA
Authorized Official - Middle Name:
Authorized Official - Last Name:PEDDIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-650-8076
Mailing Address - Street 1:3070 BRISTOL ST STE 180
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3072
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3070 BRISTOL ST STE 180
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-3072
Practice Address - Country:US
Practice Address - Phone:714-924-4824
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental