Provider Demographics
NPI:1639376825
Name:REDDY, SWETHA G (DMD)
Entity Type:Individual
Prefix:
First Name:SWETHA
Middle Name:G
Last Name:REDDY
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 1:190 MALABAR RD SW STE 104
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-2975
Mailing Address - Country:US
Mailing Address - Phone:321-914-0080
Mailing Address - Fax:
Practice Address - Street 1:190 MALABAR RD SW STE 104
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32907-2975
Practice Address - Country:US
Practice Address - Phone:321-914-0080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-29
Last Update Date:2022-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0526541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02771731Medicaid