1265506521 NPI number — DR. KISHORE K VASIREDDY DMS

Table of content: DR. KISHORE K VASIREDDY DMS (NPI 1265506521)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265506521 NPI number — DR. KISHORE K VASIREDDY DMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VASIREDDY
Provider First Name:
KISHORE
Provider Middle Name:
K
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265506521
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 PARKLAND BLVD SUITE 100
Provider Second Line Business Mailing Address:
AMERICAN DENTAL CENTER
Provider Business Mailing Address City Name:
MAYFIELD HTS
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
44124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
440-446-1555
Provider Business Mailing Address Fax Number:
440-446-1999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4957 W TUSCARAWAS
Provider Second Line Business Practice Location Address:
AMERICAN DENTAL CENTER
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
44708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
330-478-5111
Provider Business Practice Location Address Fax Number:
330-479-0518
Provider Enumeration Date:
11/20/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  18651 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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