Healthcare Provider Details

I. General information

NPI: 1659756252
Provider Name (Legal Business Name): DR. SHANTI SMITHA TELIKICHERLA KANDALA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2015
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 TACOMA ST
WORCESTER MA
01605-3516
US

IV. Provider business mailing address

650 LINCOLN ST
WORCESTER MA
01605-2060
US

V. Phone/Fax

Practice location:
  • Phone: 508-854-2122
  • Fax: 508-854-2122
Mailing address:
  • Phone: 508-852-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL12643
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL13493
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: