Provider Demographics
NPI:1619317849
Name:KATTA, KALYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KALYAN
Middle Name:
Last Name:KATTA
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 1:1049 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01103
Mailing Address - Country:US
Mailing Address - Phone:413-304-4606
Mailing Address - Fax:413-737-3608
Practice Address - Street 1:1049 MAIN STREET
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01103
Practice Address - Country:US
Practice Address - Phone:413-304-4606
Practice Address - Fax:413-737-3608
Is Sole Proprietor?:No
Enumeration Date:2013-07-02
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856342122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110028120Medicaid
MA221829Medicare Oscar/Certification
MAM21172Medicare UPIN