Provider Demographics
NPI:1831874643
Name:SHADA, LALITHA REDDY
Entity type:Individual
Prefix:
First Name:LALITHA REDDY
Middle Name:
Last Name:SHADA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8321 DONNELLEY DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78744-1522
Mailing Address - Country:US
Mailing Address - Phone:630-461-4141
Mailing Address - Fax:
Practice Address - Street 1:1600 N SARAH DEWITT DR STE 206
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:TX
Practice Address - Zip Code:78629-2714
Practice Address - Country:US
Practice Address - Phone:830-971-0268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-19
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39660122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist