Basic Information
| Provider Information | |||||||||
| NPI: | 1528164563 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KANNAN | ||||||||
| FirstName: | POONGKODI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.D.S., D.D.S. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KANNAN | ||||||||
| OtherFirstName: | KODI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | B.D.S., D.D.S. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1701 NW HAWTHORNE AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975261051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414796393 | ||||||||
| FaxNumber: | 5414796489 | ||||||||
| Practice Location | |||||||||
| Address1: | 25647 REDWOOD HWY | ||||||||
| Address2: | |||||||||
| City: | CAVE JUNCTION | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975239332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5415924111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 10/06/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | D9043 | OR | N | Dental Providers | Dentist | General Practice | 1223D0001X | D9043 | OR | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 7806250 | 05 | SD | MEDICAID |