MEDICARE: DR. REVANTH CHADA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D13666	MN
2	122300000X	Dentist	10740	KY
3	1223E0200X	Endodontics	10740	KY

General Provider Information

NPI Number	:	1528415742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REVANTH CHADA DDS

Provider Business Mailing Address
First Line	:	11212 PROFESSIONAL PARK DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-4476
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	11212 PROFESSIONAL PARK DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40291-4476
Country	:	US
Telephone Number	:	612-735-8159
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2016
Last Update Date	:	10/03/2023

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