Provider Demographics
NPI:1720391071
Name:SHIVAREDDY PETA, SHYAM PRASAD (BDS, DDS)
Entity Type:Individual
Prefix:DR
First Name:SHYAM PRASAD
Middle Name:
Last Name:SHIVAREDDY PETA
Suffix:
Gender:M
Credentials:BDS, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 1018
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-251-6999
Mailing Address - Fax:860-251-6997
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 1018
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-251-6999
Practice Address - Fax:860-251-6997
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN191791223G0001X
CT106901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice