Provider Demographics
NPI:1548781842
Name:TALLURI, SANJAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:
Last Name:TALLURI
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 1:203 TREMONT ST # 3
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-4124
Mailing Address - Country:US
Mailing Address - Phone:336-710-5672
Mailing Address - Fax:
Practice Address - Street 1:486A MAIN ST
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176-3841
Practice Address - Country:US
Practice Address - Phone:781-665-9455
Practice Address - Fax:781-712-0089
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18578981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice