Healthcare Provider Details

I. General information

NPI: 1689746711
Provider Name (Legal Business Name): CHANDUR PK WADHWANI DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12715 BEL-RED RD. SUITE 201
BELLEVUE WA
98005-2627
US

IV. Provider business mailing address

12715 BEL-RED RD SUITE 201
BELLEVUE WA
98005-2627
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-1117
  • Fax: 425-462-1878
Mailing address:
  • Phone: 425-453-1117
  • Fax: 425-462-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number10028
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE00010028
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: