Provider Demographics
NPI:1740329275
Name:JONNAVITHULA, PADMA NANDURI (DMD)
Entity type:Individual
Prefix:DR
First Name:PADMA
Middle Name:NANDURI
Last Name:JONNAVITHULA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 GREAT RD
Mailing Address - Street 2:
Mailing Address - City:ACTON
Mailing Address - State:MA
Mailing Address - Zip Code:01720-4739
Mailing Address - Country:US
Mailing Address - Phone:978-266-1614
Mailing Address - Fax:
Practice Address - Street 1:255 GREAT RD
Practice Address - Street 2:
Practice Address - City:ACTON
Practice Address - State:MA
Practice Address - Zip Code:01720-4739
Practice Address - Country:US
Practice Address - Phone:978-266-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA193461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice