Provider Demographics
NPI:1235652314
Name:BANDLA, VIJITHA
Entity Type:Individual
Prefix:DR
First Name:VIJITHA
Middle Name:
Last Name:BANDLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 WOODLAND HILLS DR
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-6360
Mailing Address - Country:US
Mailing Address - Phone:505-603-6715
Mailing Address - Fax:
Practice Address - Street 1:738 WOLCOTT ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-1336
Practice Address - Country:US
Practice Address - Phone:203-437-6213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-20
Last Update Date:2017-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT118661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice