Provider Demographics
NPI:1336589951
Name:GUDDETI, SUNIL KUMAR REDDY (DMD)
Entity Type:Individual
Prefix:
First Name:SUNIL KUMAR REDDY
Middle Name:
Last Name:GUDDETI
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 1:153 LACUESTA CT NE
Mailing Address - Street 2:
Mailing Address - City:RIORANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-6383
Mailing Address - Country:US
Mailing Address - Phone:571-484-3008
Mailing Address - Fax:
Practice Address - Street 1:6330 RIVERSIDE PLAZA LN NW STE 165
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:571-484-3008
Practice Address - Fax:505-639-4684
Is Sole Proprietor?:No
Enumeration Date:2013-06-27
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX296471223G0001X
PADS0395831223G0001X
NMDD42361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM54501334Medicaid