Provider Demographics
NPI:1023258746
Name:BANNENAHALLY, SHRUTHI Y (DDS)
Entity type:Individual
Prefix:MRS
First Name:SHRUTHI
Middle Name:Y
Last Name:BANNENAHALLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CAPANO DR
Mailing Address - Street 2:A-5
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19702-1865
Mailing Address - Country:US
Mailing Address - Phone:407-687-3470
Mailing Address - Fax:
Practice Address - Street 1:1516 SCRANTON CARBONDALE HWY
Practice Address - Street 2:346
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18508-1136
Practice Address - Country:US
Practice Address - Phone:407-687-3470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-21
Last Update Date:2009-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0377271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice