Provider Demographics
NPI:1528045184
Name:GOLLA, KEERTHI (DMD)
Entity Type:Individual
Prefix:
First Name:KEERTHI
Middle Name:
Last Name:GOLLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:539 MADISON TER
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-4872
Mailing Address - Country:US
Mailing Address - Phone:732-648-1166
Mailing Address - Fax:732-648-1166
Practice Address - Street 1:539 MADISON TER
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-4872
Practice Address - Country:US
Practice Address - Phone:732-648-1166
Practice Address - Fax:732-648-1166
Is Sole Proprietor?:No
Enumeration Date:2005-12-26
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1003981223P0221X
IL0210024421223P0221X
NY0523861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02678619Medicaid