Provider Demographics
NPI:1528415742
Name:CHADA, REVANTH (DDS)
Entity Type:Individual
Prefix:DR
First Name:REVANTH
Middle Name:
Last Name:CHADA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11212 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11212 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-4476
Practice Address - Country:US
Practice Address - Phone:612-735-8159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-17
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13666122300000X
KY10740122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No122300000XDental ProvidersDentist