Provider Demographics
NPI:1528164563
Name:KANNAN, POONGKODI (BDS, DDS)
Entity type:Individual
Prefix:DR
First Name:POONGKODI
Middle Name:
Last Name:KANNAN
Suffix:
Gender:F
Credentials:BDS, DDS
Other - Prefix:DR
Other - First Name:KODI
Other - Middle Name:
Other - Last Name:KANNAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:BDS, DDS
Mailing Address - Street 1:1701 NW HAWTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1051
Mailing Address - Country:US
Mailing Address - Phone:541-479-6393
Mailing Address - Fax:541-479-6489
Practice Address - Street 1:25647 REDWOOD HWY
Practice Address - Street 2:
Practice Address - City:CAVE JUNCTION
Practice Address - State:OR
Practice Address - Zip Code:97523-9332
Practice Address - Country:US
Practice Address - Phone:541-592-4111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD90431223G0001X, 1223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD7806250Medicaid