Healthcare Provider Details

I. General information

NPI: 1053253880
Provider Name (Legal Business Name): KEERTHI PRASANNA CHENNURI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 FAIRVIEW ST
CLINTON NC
28328-2311
US

IV. Provider business mailing address

411 FAIRVIEW ST
CLINTON NC
28328-2311
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-3516
  • Fax: 910-592-0530
Mailing address:
  • Phone: 910-592-3516
  • Fax: 910-592-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number15016
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019037113
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: