Healthcare Provider Details

I. General information

NPI: 1023258746
Provider Name (Legal Business Name): SHRUTHI Y BANNENAHALLY DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2009
Last Update Date: 02/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1516 SCRANTON CARBONDALE HWY 346
SCRANTON PA
18508-1136
US

IV. Provider business mailing address

1 CAPANO DR A-5
NEWARK DE
19702-1865
US

V. Phone/Fax

Practice location:
  • Phone: 407-687-3470
  • Fax:
Mailing address:
  • Phone: 407-687-3470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS037727
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: