Provider Demographics
NPI:1306480298
Name:IMMELLA, SOUMYA (DMD)
Entity type:Individual
Prefix:DR
First Name:SOUMYA
Middle Name:
Last Name:IMMELLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N KROCKS RD STE 206
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18106-9079
Mailing Address - Country:US
Mailing Address - Phone:610-530-7785
Mailing Address - Fax:610-435-7606
Practice Address - Street 1:1536 CROSSLAND RD
Practice Address - Street 2:
Practice Address - City:BREINIGSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18031-1471
Practice Address - Country:US
Practice Address - Phone:484-934-2305
Practice Address - Fax:610-435-7606
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-04
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0423991223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1035882000001Medicaid