Healthcare Provider Details

I. General information

NPI: 1528045184
Provider Name (Legal Business Name): KEERTHI GOLLA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2005
Last Update Date: 04/06/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

539 MADISON TER
SUNNYVALE CA
94087-4872
US

IV. Provider business mailing address

539 MADISON TER
SUNNYVALE CA
94087-4872
US

V. Phone/Fax

Practice location:
  • Phone: 732-648-1166
  • Fax: 732-648-1166
Mailing address:
  • Phone: 732-648-1166
  • Fax: 732-648-1166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number052386
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number100398
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021002442
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: