Provider Demographics
NPI:1407846793
Name:VALLABHANENI, JAYA (DDS)
Entity Type:Individual
Prefix:DR
First Name:JAYA
Middle Name:
Last Name:VALLABHANENI
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 1:625 SAINT REGIS LN
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-1653
Mailing Address - Country:US
Mailing Address - Phone:770-993-1284
Mailing Address - Fax:
Practice Address - Street 1:3273 SHALLOWFORD RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30341-3632
Practice Address - Country:US
Practice Address - Phone:770-455-0628
Practice Address - Fax:770-451-7521
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN 0122731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA853472301BMedicaid