Provider Demographics
NPI:1659756252
Name:TELIKICHERLA KANDALA, SHANTI SMITHA
Entity Type:Individual
Prefix:DR
First Name:SHANTI SMITHA
Middle Name:
Last Name:TELIKICHERLA KANDALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:508-852-1805
Mailing Address - Fax:
Practice Address - Street 1:19 TACOMA ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3516
Practice Address - Country:US
Practice Address - Phone:508-854-2122
Practice Address - Fax:508-854-2122
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL12643122300000X
MADL13493122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist