Basic Information
| Provider Information | |||||||||
| NPI: | 1730461203 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RETHIYAMMA | ||||||||
| FirstName: | REKHA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 W 8TH ST | ||||||||
| Address2: | SUITE 810 | ||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195624447 | ||||||||
| FaxNumber: | 7195831801 | ||||||||
| Practice Location | |||||||||
| Address1: | 2332 MIRACLE LN | ||||||||
| Address2: | |||||||||
| City: | MISHAWAKA | ||||||||
| State: | IN | ||||||||
| PostalCode: | 465453012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5742595437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2011 | ||||||||
| LastUpdateDate: | 09/12/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 9108 | KY | Y | Dental Providers | Dentist | General Practice |
No ID Information.