MEDICARE: DR. REENA KANDYALA D.D.S

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	1223G0001X	General Practice Dentistry	DEN.00203424	CO
2	1223G0001X	General Practice Dentistry	12679	CT
3	1223G0001X	General Practice Dentistry	DN1859260	MA

General Provider Information

NPI Number	:	1720596778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. REENA KANDYALA D.D.S

Provider Business Mailing Address
First Line	:	11-4 ARTHUR DR
Second Line	:
City	:	SOUTH WINDSOR
State	:	CT
Zip	:	06074-3673
Country	:	US
Telephone Number	:	832-841-5878
Fax Number	:

Provider Business Practice Location Address
First Line	:	1070 SAINT JAMES AVE
Second Line	:
City	:	SPRINGFIELD
State	:	MA
Zip	:	01104-1453
Country	:	US
Telephone Number	:	413-278-6904
Fax Number	:

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

Provider Enumeration Date	:	01/11/2018
Last Update Date	:	12/08/2021

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