Provider Demographics
NPI:1528260585
Name:NAIDU, KISTAMA (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:KISTAMA
Middle Name:
Last Name:NAIDU
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18503 PINES BLVD
Mailing Address - Street 2:SUITE# 304
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1404
Mailing Address - Country:US
Mailing Address - Phone:954-805-3588
Mailing Address - Fax:
Practice Address - Street 1:18503 PINES BLVD
Practice Address - Street 2:SUITE# 304
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1404
Practice Address - Country:US
Practice Address - Phone:954-805-3588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 170021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics