Provider Demographics
NPI:1730432162
Name:VIJAY GADDAM PC
Entity type:Organization
Organization Name:VIJAY GADDAM PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIJAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GADDAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-785-5566
Mailing Address - Street 1:43 SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2415
Mailing Address - Country:US
Mailing Address - Phone:413-785-5566
Mailing Address - Fax:413-785-5568
Practice Address - Street 1:43 SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2415
Practice Address - Country:US
Practice Address - Phone:413-785-5566
Practice Address - Fax:413-785-5568
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222261223G0001X
CT0105201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty