Healthcare Provider Details

I. General information

NPI: 1417413139
Provider Name (Legal Business Name): SHRUTI CHANDNA DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 MONTGOMERY HWY STE 8
DOTHAN AL
36303-1657
US

IV. Provider business mailing address

1011 N UNIVERSITY AVE
ANN ARBOR MI
48109-1078
US

V. Phone/Fax

Practice location:
  • Phone: 334-983-1730
  • Fax:
Mailing address:
  • Phone: 601-668-8412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1341
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2951000806
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD.007245-C1
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: