Provider Demographics
NPI:1811549181
Name:MUTTANAHALLY, KAVYA SHANKAR
Entity Type:Individual
Prefix:MS
First Name:KAVYA SHANKAR
Middle Name:
Last Name:MUTTANAHALLY
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 1:33 LAKESHORE DR APT B2
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1268
Mailing Address - Country:US
Mailing Address - Phone:860-725-2104
Mailing Address - Fax:
Practice Address - Street 1:UCONN SCHOOL OF DENTAL MEDICINE 263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-2952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program