Provider Demographics
NPI:1215437389
Name:PARVATHA REDDY, MAHENDRA (DDS)
Entity type:Individual
Prefix:DR
First Name:MAHENDRA
Middle Name:
Last Name:PARVATHA REDDY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1407 W 84TH AVE UNIT B8
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80260-4753
Practice Address - Country:US
Practice Address - Phone:720-214-4746
Practice Address - Fax:720-214-4745
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO203806122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CODEN.00203806OtherCO DENTAL LICENSE
CO1215437389Medicaid