=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760277206
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KUPPERI AND KOMMINENI DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/14/2025
-----------------------------------------------------
Last Update Date | 04/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1619 S PROVIDENCE RD STE 120
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-0424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-627-8327
-----------------------------------------------------
Fax | 704-370-9571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1619 S PROVIDENCE RD STE 120
-----------------------------------------------------
City | WAXHAW
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28173-0424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-627-8327
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR/MANAGER
-----------------------------------------------------
Name | DR. SANATH KOMMINENI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 980-256-8817
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------