Provider Demographics
NPI:1962001149
Name:KONDREDDI, KALYAN CHAKRAVARTHY (DMD)
Entity Type:Individual
Prefix:
First Name:KALYAN
Middle Name:CHAKRAVARTHY
Last Name:KONDREDDI
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 1:30 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-7102
Mailing Address - Country:US
Mailing Address - Phone:781-391-2440
Mailing Address - Fax:
Practice Address - Street 1:30 MAIN ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-7102
Practice Address - Country:US
Practice Address - Phone:781-391-2440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice