Provider Demographics
NPI:1891848321
Name:REDDI, SANJAY (BDS, MD)
Entity Type:Individual
Prefix:
First Name:SANJAY
Middle Name:
Last Name:REDDI
Suffix:
Gender:M
Credentials:BDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2453 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4232
Mailing Address - Country:US
Mailing Address - Phone:432-333-6585
Mailing Address - Fax:432-333-9346
Practice Address - Street 1:2453 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4232
Practice Address - Country:US
Practice Address - Phone:432-333-6585
Practice Address - Fax:432-333-9346
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX210451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery