Provider Demographics
NPI:1386734259
Name:NALLA, SUMAN REDDY (DMD)
Entity type:Individual
Prefix:DR
First Name:SUMAN
Middle Name:REDDY
Last Name:NALLA
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 1:3310 LIVE OAK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75204-6153
Mailing Address - Country:US
Mailing Address - Phone:214-827-1305
Mailing Address - Fax:
Practice Address - Street 1:3310 LIVE OAK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75204-6153
Practice Address - Country:US
Practice Address - Phone:214-827-1305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH3263122300000X
TX259491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist