Healthcare Provider Details

I. General information

NPI: 1700206786
Provider Name (Legal Business Name): HEMANTH KUNDURU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 WEST 12TH AVENUE ROOM 2039-K POSTLE HALL
COLUMBUS OH
43210
US

IV. Provider business mailing address

305 WEST 12TH AVENUE ROOM 2039-K POSTLE HALL
COLUMBUS OH
43210
US

V. Phone/Fax

Practice location:
  • Phone: 614-292-2622
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.024378
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: