Provider Demographics
NPI:1689045924
Name:CHENNADI, SUMAN
Entity Type:Individual
Prefix:
First Name:SUMAN
Middle Name:
Last Name:CHENNADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08876-2110
Mailing Address - Country:US
Mailing Address - Phone:908-725-0400
Mailing Address - Fax:
Practice Address - Street 1:15 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SOMERVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08876-2110
Practice Address - Country:US
Practice Address - Phone:908-725-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-13
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02614400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI02614400OtherNJ DENTAL BOARD