Provider Demographics
NPI:1568861292
Name:BADDAM, SRUJANA
Entity type:Individual
Prefix:
First Name:SRUJANA
Middle Name:
Last Name:BADDAM
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 1:1300 PEACHTREE INDUSTRIAL BLVD STE 2203
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4552
Mailing Address - Country:US
Mailing Address - Phone:470-508-0053
Mailing Address - Fax:470-508-0053
Practice Address - Street 1:656 INDIAN TRL RD NW STE 206
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6872
Practice Address - Country:US
Practice Address - Phone:770-806-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-19
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO14858122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist