Healthcare Provider Details

I. General information

NPI: 1255528360
Provider Name (Legal Business Name): CHIRDEEP MYSORE CHANDRAKEERTHI BDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2007
Last Update Date: 09/08/2021
Certification Date: 09/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7032 E COCHISE RD A220
SCOTTSDALE AZ
85253
US

IV. Provider business mailing address

7032 E COCHISE RD A220
SCOTTSDALE AZ
85253
US

V. Phone/Fax

Practice location:
  • Phone: 480-443-8440
  • Fax: 480-443-4767
Mailing address:
  • Phone: 480-443-8440
  • Fax: 480-443-4767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD9020
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN015335
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number10558
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: