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General NPI Number Information
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NPI Number | 1801540281
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Entity Type | Individual
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Provider Name | LEELA BUDDARAJU
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Gender | Female
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Dates
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Enumeration Date | 02/04/2022
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Last Update Date | 02/04/2022
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Provider Practice Location Address
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Address Line | 6430 GREEN BAY RD STE 112
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City | KENOSHA
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State | WI
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Zip | 53142-2948
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Country | US
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Telephone | 262-653-3980
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Fax |
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Provider Business Mailing Address
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Address Line | 2494 WATERBURY LN
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City | BUFFALO GROVE
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State | IL
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Zip | 60089-6890
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Country | US
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Telephone | 224-334-9307
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 100274915
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License Number State | WI
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