Provider Demographics
NPI:1518120013
Name:KALLAM, VENU (DMD)
Entity Type:Individual
Prefix:DR
First Name:VENU
Middle Name:
Last Name:KALLAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 KENNEDY DR
Mailing Address - Street 2:APT 08
Mailing Address - City:MALDEN
Mailing Address - State:MA
Mailing Address - Zip Code:02148-3431
Mailing Address - Country:US
Mailing Address - Phone:215-301-8655
Mailing Address - Fax:
Practice Address - Street 1:175 UNION ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1310
Practice Address - Country:US
Practice Address - Phone:781-592-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2013-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN22210Medicaid