=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821498163
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AVANIJA REDDY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2014
-----------------------------------------------------
Last Update Date | 08/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 107 BONNABROOK DR
-----------------------------------------------------
City | HERMITAGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37076-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 615-889-1654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 107 BONNABROOK DR
-----------------------------------------------------
City | HERMITAGE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37076-1910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 9893
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------