Provider Demographics
NPI:1821250820
Name:GADDAM, VIJAY BHASKAR REDDY (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIJAY BHASKAR
Middle Name:REDDY
Last Name:GADDAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 RAILROAD ST
Mailing Address - Street 2:2B
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-3573
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1073 RIVERDALE ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-4614
Practice Address - Country:US
Practice Address - Phone:413-285-7114
Practice Address - Fax:413-285-7168
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-30
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX257791223G0001X
MA222261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9211482Medicaid