Healthcare Provider Details

I. General information

NPI: 1720494370
Provider Name (Legal Business Name): SIRIN CHUNDU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 03/26/2021
Certification Date: 03/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 LAKELAND DR
CHIPPEWA FALLS WI
54729
US

IV. Provider business mailing address

850 LAKELAND DR
CHIPPEWA FALLS WI
54729-1687
US

V. Phone/Fax

Practice location:
  • Phone: 715-738-2000
  • Fax:
Mailing address:
  • Phone: 715-738-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30209
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number059610
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1002288-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: