Provider Demographics
NPI:1821429614
Name:BOMMU, SANJAY REDDY (DMD)
Entity Type:Individual
Prefix:DR
First Name:SANJAY
Middle Name:REDDY
Last Name:BOMMU
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 1:49 CROSS STREET EXT
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2209
Mailing Address - Country:US
Mailing Address - Phone:978-632-5659
Mailing Address - Fax:978-632-5713
Practice Address - Street 1:49 CROSS STREET EXT
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2209
Practice Address - Country:US
Practice Address - Phone:978-632-5659
Practice Address - Fax:978-632-5713
Is Sole Proprietor?:No
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18564341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice