Provider Demographics
NPI:1396113064
Name:DIAMOND DENTAL LLC
Entity type:Organization
Organization Name:DIAMOND DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RATNA
Authorized Official - Middle Name:
Authorized Official - Last Name:VEDULLAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:908-930-1938
Mailing Address - Street 1:274 S MAIN ST
Mailing Address - Street 2:UNIT C9
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-6705
Mailing Address - Country:US
Mailing Address - Phone:203-403-2446
Mailing Address - Fax:
Practice Address - Street 1:274 S MAIN ST
Practice Address - Street 2:UNIT C9
Practice Address - City:NEWTOWN
Practice Address - State:CT
Practice Address - Zip Code:06470-6705
Practice Address - Country:US
Practice Address - Phone:203-403-2446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010135305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1720217953OtherNPPES