Provider Demographics
NPI:1982718136
Name:KOMANDUR, KANNAN (DDS)
Entity Type:Individual
Prefix:
First Name:KANNAN
Middle Name:
Last Name:KOMANDUR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 SUNSET LN
Mailing Address - Street 2:SUITE 5
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6199
Mailing Address - Country:US
Mailing Address - Phone:925-778-2400
Mailing Address - Fax:925-778-2427
Practice Address - Street 1:3700 SUNSET LN
Practice Address - Street 2:SUITE 5
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6199
Practice Address - Country:US
Practice Address - Phone:925-778-2400
Practice Address - Fax:925-778-2427
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA506271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050627Medicare ID - Type Unspecified