Provider Demographics
NPI:1629591854
Name:TADAKAMALLA, PRAMOD (DDS)
Entity Type:Individual
Prefix:
First Name:PRAMOD
Middle Name:
Last Name:TADAKAMALLA
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 1:907 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-2401
Mailing Address - Country:US
Mailing Address - Phone:716-548-3741
Mailing Address - Fax:
Practice Address - Street 1:907 S 6TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-2401
Practice Address - Country:US
Practice Address - Phone:716-548-3741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2017-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031274122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist