Provider Demographics
NPI:1700206786
Name:KUNDURU, HEMANTH
Entity Type:Individual
Prefix:
First Name:HEMANTH
Middle Name:
Last Name:KUNDURU
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 1:305 WEST 12TH AVENUE
Mailing Address - Street 2:ROOM 2039-K POSTLE HALL
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:305 WEST 12TH AVENUE
Practice Address - Street 2:ROOM 2039-K POSTLE HALL
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210
Practice Address - Country:US
Practice Address - Phone:614-292-2622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-17
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.024378122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program