Provider Demographics
NPI:1326037128
Name:KUNTHARA, PREETHY JACOB (DDS)
Entity Type:Individual
Prefix:DR
First Name:PREETHY
Middle Name:JACOB
Last Name:KUNTHARA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 S LONGMORE
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-9603
Mailing Address - Country:US
Mailing Address - Phone:480-833-0880
Mailing Address - Fax:480-833-0225
Practice Address - Street 1:1350 S LONGMORE
Practice Address - Street 2:SUITE 13
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-9603
Practice Address - Country:US
Practice Address - Phone:480-833-0880
Practice Address - Fax:480-833-0225
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD56441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ752114Medicare ID - Type UnspecifiedAHCCCS