Healthcare Provider Details

I. General information

NPI: 1598074619
Provider Name (Legal Business Name): SIMHA VAIBHAVA REDDY KUKUNOORU B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1799 66TH ST N
ST PETERSBURG FL
33710-5537
US

IV. Provider business mailing address

1799 66TH ST N
ST PETERSBURG FL
33710-5537
US

V. Phone/Fax

Practice location:
  • Phone: 727-222-3220
  • Fax:
Mailing address:
  • Phone: 205-807-6322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN19262
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: