Provider Demographics
NPI:1417413139
Name:CHANDNA, SHRUTI (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SHRUTI
Middle Name:
Last Name:CHANDNA
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 N UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-1078
Mailing Address - Country:US
Mailing Address - Phone:601-668-8412
Mailing Address - Fax:
Practice Address - Street 1:5412 MONTGOMERY HWY STE 8
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1657
Practice Address - Country:US
Practice Address - Phone:334-983-1730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29510008061223G0001X
ALD.007245-C11223P0221X
OK1341122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2951000806OtherBOARD OF DENTISTRY DENTAL EDUCATION LIMITED LICENSE