Provider Demographics
NPI:1770224107
Name:SWETHA REDDY & PAVAN KANCHARLA LLC
Entity Type:Organization
Organization Name:SWETHA REDDY & PAVAN KANCHARLA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SWETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:321-576-4825
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:321-576-4825
Mailing Address - Fax:321-241-3002
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:321-576-4825
Practice Address - Fax:321-241-3002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-07
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty