Provider Demographics
NPI:1023790292
Name:REDDY, AMITA
Entity type:Individual
Prefix:
First Name:AMITA
Middle Name:
Last Name:REDDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 PALMER DR NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-9515
Mailing Address - Country:US
Mailing Address - Phone:706-266-7175
Mailing Address - Fax:
Practice Address - Street 1:755 COMMERCE DR STE 600
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2619
Practice Address - Country:US
Practice Address - Phone:404-373-7818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN123162122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist