Basic Information
| Provider Information | |||||||||
| NPI: | 1649589151 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KALA SAGAR MADUGULA DMD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5700 YOUNGSTOWN WARREN RD | ||||||||
| Address2: | UNIT 107 | ||||||||
| City: | NILES | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444464762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306523900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2010 | ||||||||
| LastUpdateDate: | 09/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | MADUGULA | ||||||||
| AuthorizedOfficialFirstName: | KALA | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3306523900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DMD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.