Healthcare Provider Details

I. General information

NPI: 1447608443
Provider Name (Legal Business Name): SIREESHA KODALI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2016
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S DOBSON RD
CHANDLER AZ
85224-5678
US

IV. Provider business mailing address

2849 E BOOT TRACK TRL
GILBERT AZ
85296-0586
US

V. Phone/Fax

Practice location:
  • Phone: 480-820-6778
  • Fax: 623-344-3007
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD009876
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number9770
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: