Healthcare Provider Details

I. General information

NPI: 1861314775
Provider Name (Legal Business Name): GAURAV ADDAGATLA DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E CARSON ST STE 101
CARSON CA
90745-2896
US

IV. Provider business mailing address

647 CHANNEL WAY
COSTA MESA CA
92627-3690
US

V. Phone/Fax

Practice location:
  • Phone: 310-469-9355
  • Fax:
Mailing address:
  • Phone: 916-749-8152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS113414
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: