Healthcare Provider Details

I. General information

NPI: 1760277206
Provider Name (Legal Business Name): KUPPERI AND KOMMINENI DDS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2025
Last Update Date: 04/14/2025
Certification Date: 04/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1619 S PROVIDENCE RD STE 120
WAXHAW NC
28173-0424
US

IV. Provider business mailing address

1619 S PROVIDENCE RD STE 120
WAXHAW NC
28173-0424
US

V. Phone/Fax

Practice location:
  • Phone: 704-627-8327
  • Fax: 704-370-9571
Mailing address:
  • Phone: 704-627-8327
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. SANATH KOMMINENI
Title or Position: DOCTOR/MANAGER
Credential:
Phone: 980-256-8817