Basic Information
| Provider Information | |||||||||
| NPI: | 1952303885 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TUMMALA | ||||||||
| FirstName: | SHEELA | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 MAIN ST | ||||||||
| Address2: | ATTN: CREDENTIALING DPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | 8606386601 | ||||||||
| Practice Location | |||||||||
| Address1: | 165 MILLER ST | ||||||||
| Address2: | 2ND FLOOR | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064504256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036393500 | ||||||||
| FaxNumber: | 2036393509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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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 | 009394 | CT | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 004236354 | 05 | CT | MEDICAID |