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General NPI Number Information
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NPI Number | 1265675680
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Entity Type | Individual
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Provider Name | PRAVEEN KUMAR GAJENDRAREDDY DDS
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Gender | Male
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Dates
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Enumeration Date | 04/15/2009
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Last Update Date | 12/13/2011
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Provider Practice Location Address
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Address Line | 801 S PAULINA ST M/C 621
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City | CHICAGO
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State | IL
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Zip | 60612-7210
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Country | US
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Telephone | 614-657-8312
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Fax |
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Provider Business Mailing Address
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Address Line | 1841 MAINE DR
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City | ELK GROVE VILLAGE
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State | IL
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Zip | 60007-2728
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Country | US
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Telephone | 614-657-8312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 021.002403
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License Number State | IL
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