Provider Demographics
NPI:1063942241
Name:REDDY, NITYA (DDS)
Entity type:Individual
Prefix:DR
First Name:NITYA
Middle Name:
Last Name:REDDY
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 1:520 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298-5064
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 N 12TH ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5064
Practice Address - Country:US
Practice Address - Phone:804-828-9356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-19
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04420003681223P0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0442000368OtherTEMPORARY RESIDENT DENTAL LICENSE IN VA