Healthcare Provider Details

I. General information

NPI: 1700878782
Provider Name (Legal Business Name): GOPAL REDDY YETURU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14285 AMAR RD
LA PUENTE CA
91746-2154
US

IV. Provider business mailing address

6682 CARRIAGE CIR
HUNTINGTON BEACH CA
92648-1501
US

V. Phone/Fax

Practice location:
  • Phone: 626-917-9308
  • Fax:
Mailing address:
  • Phone: 714-848-9209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number24734
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: