Healthcare Provider Details

I. General information

NPI: 1447425392
Provider Name (Legal Business Name): RAJU REDDY DDS,MD,INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BIRCH ST SUITE 110
REDWOOD CITY CA
94062-1480
US

IV. Provider business mailing address

11 BIRCH ST SUITE 110
REDWOOD CITY CA
94062-1480
US

V. Phone/Fax

Practice location:
  • Phone: 650-387-6517
  • Fax: 650-362-1980
Mailing address:
  • Phone: 650-387-6517
  • Fax: 650-362-1980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberA80394
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberGA 1293
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License NumberOMS46
License Number StateCA

VIII. Authorized Official

Name: RAJU YEDDULA REDDY
Title or Position: PRESIDENT
Credential: DDS,MD
Phone: 650-387-6517