Provider Demographics
NPI:1902927825
Name:KOTHAPALLI, SAMANTHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:
Last Name:KOTHAPALLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 COUNTRY LAKES DR
Mailing Address - Street 2:202
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60563-9041
Mailing Address - Country:US
Mailing Address - Phone:630-803-6431
Mailing Address - Fax:
Practice Address - Street 1:968 BROOK FOREST AVE
Practice Address - Street 2:UNIT B1
Practice Address - City:SHOREWOOD
Practice Address - State:IL
Practice Address - Zip Code:60431-8807
Practice Address - Country:US
Practice Address - Phone:815-254-1177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9178915Medicaid