Provider Demographics
NPI:1265975312
Name:CHANDRUPATLA, SIDDARDHA (DDS MMSC)
Entity type:Individual
Prefix:DR
First Name:SIDDARDHA
Middle Name:
Last Name:CHANDRUPATLA
Suffix:
Gender:M
Credentials:DDS MMSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15132 OLD GALVESTON RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:TX
Mailing Address - Zip Code:77598-1821
Mailing Address - Country:US
Mailing Address - Phone:281-990-7462
Mailing Address - Fax:
Practice Address - Street 1:15132 OLD GALVESTON RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:TX
Practice Address - Zip Code:77598-1821
Practice Address - Country:US
Practice Address - Phone:281-990-7462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-22
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX33470122300000X, 1223G0001X, 1223D0001X
MADL129351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice