Provider Demographics
NPI:1194403485
Name:KODALI, GIDEON PRASANTH (DMD)
Entity type:Individual
Prefix:DR
First Name:GIDEON PRASANTH
Middle Name:
Last Name:KODALI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6334 SE IMAGINE WAY
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-5059
Mailing Address - Country:US
Mailing Address - Phone:270-363-5624
Mailing Address - Fax:
Practice Address - Street 1:15715 NW CENTRAL DR STE 7
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97229-1267
Practice Address - Country:US
Practice Address - Phone:503-610-4038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-07
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD11813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist