Provider Demographics
NPI:1841365863
Name:PONNALA, SRIDEVI (DDS)
Entity type:Individual
Prefix:DR
First Name:SRIDEVI
Middle Name:
Last Name:PONNALA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22331 MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-3911
Mailing Address - Country:US
Mailing Address - Phone:510-471-5907
Mailing Address - Fax:510-324-1359
Practice Address - Street 1:22331 MISSION BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-3911
Practice Address - Country:US
Practice Address - Phone:510-471-5907
Practice Address - Fax:510-324-1359
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530261223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health