Provider Demographics
NPI:1821375809
Name:CHANDU, GANGADHARA
Entity Type:Individual
Prefix:
First Name:GANGADHARA
Middle Name:
Last Name:CHANDU
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 1:400 RED BROOK BLVD
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5172
Mailing Address - Country:US
Mailing Address - Phone:312-121-2222
Mailing Address - Fax:
Practice Address - Street 1:400 RED BROOK BLVD
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5172
Practice Address - Country:US
Practice Address - Phone:312-121-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA44444444444444444444126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant