Provider Demographics
NPI:1154569077
Name:KELLA, GUNJAN PRASAD (DDS)
Entity type:Individual
Prefix:DR
First Name:GUNJAN
Middle Name:PRASAD
Last Name:KELLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10811 WASHINGTON BLVD STE 302
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-3660
Mailing Address - Country:US
Mailing Address - Phone:310-839-8033
Mailing Address - Fax:
Practice Address - Street 1:10811 WASHINGTON BLVD STE 302
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-3660
Practice Address - Country:US
Practice Address - Phone:310-839-8033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2024-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1000471223G0001X
NY100047122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice