Provider Demographics
NPI:1407212558
Name:SIDDHI ANITHA PRASANNA
Entity Type:Organization
Organization Name:SIDDHI ANITHA PRASANNA
Other - Org Name:STELLAR SMILE FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMIN OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GLENNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-268-0108
Mailing Address - Street 1:815 CHENEY HWY
Mailing Address - Street 2:
Mailing Address - City:TITUSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32780-6960
Mailing Address - Country:US
Mailing Address - Phone:321-268-0108
Mailing Address - Fax:321-269-6033
Practice Address - Street 1:815 CHENEY HWY
Practice Address - Street 2:
Practice Address - City:TITUSVILLE
Practice Address - State:FL
Practice Address - Zip Code:32780-6960
Practice Address - Country:US
Practice Address - Phone:321-268-0108
Practice Address - Fax:321-269-6033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty