Healthcare Provider Details

I. General information

NPI: 1821375809
Provider Name (Legal Business Name): GANGADHARA CHANDU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 RED BROOK BLVD
OWINGS MILLS MD
21117-5172
US

IV. Provider business mailing address

400 RED BROOK BLVD
OWINGS MILLS MD
21117-5172
US

V. Phone/Fax

Practice location:
  • Phone: 312-121-2222
  • Fax:
Mailing address:
  • Phone: 312-121-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number44444444444444444444
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: