Healthcare Provider Details

I. General information

NPI: 1326278300
Provider Name (Legal Business Name): SAI VENKATA MAHESH GUDURU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5015 W RIDGE RUN
CANANDAIGUA NY
14424-2731
US

IV. Provider business mailing address

430 W ERIE ST STE 200
CHICAGO IL
60654-6914
US

V. Phone/Fax

Practice location:
  • Phone: 617-416-0270
  • Fax:
Mailing address:
  • Phone: 312-274-0308
  • Fax: 312-944-9499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number059482-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: