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General NPI Number Information
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NPI Number | 1528881323
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Entity Type | Individual
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Provider Name | DR. DIVIJA TAKKALAPELLY
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Gender | Female
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Dates
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Enumeration Date | 11/01/2024
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Last Update Date | 01/23/2025
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Provider Practice Location Address
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Address Line | 989 ELLIS AVE
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City | JACKSON
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State | MS
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Zip | 39209-6256
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Country | US
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Telephone | 769-235-3019
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Fax |
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Provider Business Mailing Address
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Address Line | 989 ELLIS AVE
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City | JACKSON
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State | MS
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Zip | 39209-6256
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Country | US
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Telephone | 210-867-6961
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 4488-24
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License Number State | MS
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 7626
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License Number State | LA
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | OR-6079-25
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License Number State | MS
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