Provider Demographics
NPI:1801540281
Name:BUDDARAJU, LEELA
Entity type:Individual
Prefix:
First Name:LEELA
Middle Name:
Last Name:BUDDARAJU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2494 WATERBURY LN
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6890
Mailing Address - Country:US
Mailing Address - Phone:224-334-9307
Mailing Address - Fax:
Practice Address - Street 1:6430 GREEN BAY RD STE 112
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-2948
Practice Address - Country:US
Practice Address - Phone:262-653-3980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1002749151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice