Provider Demographics
NPI:1518120013
Name:KALLAM, VENU (DMD)
Entity type:Individual
Prefix:DR
First Name:VENU
Middle Name:
Last Name:KALLAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:439 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:MA
Mailing Address - Zip Code:02149-3612
Mailing Address - Country:US
Mailing Address - Phone:617-944-9627
Mailing Address - Fax:
Practice Address - Street 1:439 BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:MA
Practice Address - Zip Code:02149-3612
Practice Address - Country:US
Practice Address - Phone:617-944-9627
Practice Address - Fax:617-944-9742
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN22210Medicaid