Provider Demographics
NPI:1164471363
Name:VEERANNA, SUPREETH L
Entity Type:Individual
Prefix:
First Name:SUPREETH
Middle Name:L
Last Name:VEERANNA
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 1:74 ELMCREST DR
Mailing Address - Street 2:
Mailing Address - City:CHICOPEE
Mailing Address - State:MA
Mailing Address - Zip Code:01013-3339
Mailing Address - Country:US
Mailing Address - Phone:617-275-3216
Mailing Address - Fax:617-275-3216
Practice Address - Street 1:74 ELMCREST DR
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01013-3339
Practice Address - Country:US
Practice Address - Phone:617-275-3216
Practice Address - Fax:617-275-3216
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0223101223G0001X
MADN212741223P0221X
CT108181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2636722Medicaid
MA110008505AMedicaid