Provider Demographics
NPI:1962074377
Name:BANDA, THIRUPATHI REDDY
Entity type:Individual
Prefix:
First Name:THIRUPATHI REDDY
Middle Name:
Last Name:BANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7866 MINERAL POINT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53717-2028
Mailing Address - Country:US
Mailing Address - Phone:608-422-4746
Mailing Address - Fax:608-467-1229
Practice Address - Street 1:7866 MINERAL POINT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-2028
Practice Address - Country:US
Practice Address - Phone:608-422-4746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002645122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist