MEDICARE: DR. SRAVANTHI GANNE DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DN19304	FL

General Provider Information

NPI Number	:	1972764967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SRAVANTHI GANNE DDS

Provider Business Mailing Address
First Line	:	1728 DUNLAWTON AVE STE 3
Second Line	:
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2923
Country	:	US
Telephone Number	:	412-913-8877
Fax Number	:	844-704-4268

Provider Business Practice Location Address
First Line	:	1728 DUNLAWTON AVE STE 3
Second Line	:	APARTMENT 2G
City	:	PORT ORANGE
State	:	FL
Zip	:	32127-2923
Country	:	US
Telephone Number	:	412-913-8877
Fax Number	:	844-704-4268

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2008
Last Update Date	:	11/22/2021

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