Healthcare Provider Details

I. General information

NPI: 1225737380
Provider Name (Legal Business Name): NIKHIL KALLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2756 CHURCH ST
CONWAY SC
29526-4406
US

IV. Provider business mailing address

108 OAK CREEK WAY APT 3309
NEW BRAUNFELS TX
78130-7690
US

V. Phone/Fax

Practice location:
  • Phone: 843-438-4210
  • Fax:
Mailing address:
  • Phone: 325-660-5474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11487
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: