Healthcare Provider Details

I. General information

NPI: 1316353477
Provider Name (Legal Business Name): KASHYAP MADDALI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 07/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N ALPINE RD
ROCKFORD IL
61107-2262
US

IV. Provider business mailing address

1301 N ALPINE RD
ROCKFORD IL
61107-2262
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-4280
  • Fax: 815-484-2436
Mailing address:
  • Phone: 815-397-4280
  • Fax: 815-484-2436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.029910
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: