Provider Demographics
NPI:1245372812
Name:MADDALI, KALYANI (DDS)
Entity type:Individual
Prefix:DR
First Name:KALYANI
Middle Name:
Last Name:MADDALI
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 1:2810 MORRIS AVE SUITE 202
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083
Mailing Address - Country:US
Mailing Address - Phone:908-851-9292
Mailing Address - Fax:908-851-9899
Practice Address - Street 1:2810 MORRIS AVE SUITE 202
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083
Practice Address - Country:US
Practice Address - Phone:908-851-9292
Practice Address - Fax:908-851-9899
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D102182400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ538150OtherAETNA DMU
NJ0021555Medicaid