Provider Demographics
NPI:1477743524
Name:KANDIMALLA, KALPANA NAGADEEPTHI (DDS)
Entity Type:Individual
Prefix:DR
First Name:KALPANA
Middle Name:NAGADEEPTHI
Last Name:KANDIMALLA
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 1:772 S WEBER RD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60490-5472
Mailing Address - Country:US
Mailing Address - Phone:630-518-2272
Mailing Address - Fax:630-243-4778
Practice Address - Street 1:772 S WEBER RD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60490-5472
Practice Address - Country:US
Practice Address - Phone:630-518-2272
Practice Address - Fax:630-243-4778
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019027242122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist