Provider Demographics
NPI:1821404864
Name:ACHALLA, VENKATA
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:
Last Name:ACHALLA
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 1:2330 W PIERCE ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-3514
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:
Practice Address - Street 1:2050 E ALGONQUIN RD
Practice Address - Street 2:610
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4144
Practice Address - Country:US
Practice Address - Phone:847-701-1457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD41441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice