Provider Demographics
NPI:1528881323
Name:TAKKALAPELLY, DIVIJA
Entity type:Individual
Prefix:DR
First Name:DIVIJA
Middle Name:
Last Name:TAKKALAPELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:989 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39209-6256
Mailing Address - Country:US
Mailing Address - Phone:210-867-6961
Mailing Address - Fax:
Practice Address - Street 1:989 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39209-6256
Practice Address - Country:US
Practice Address - Phone:769-235-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-01
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS4488-241223X0400X
LA76261223X0400X
MSOR-6079-251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics