Healthcare Provider Details

I. General information

NPI: 1790148294
Provider Name (Legal Business Name): DENTAL BRACES GURU PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2016
Last Update Date: 02/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11330 WILES RD
CORAL SPRINGS FL
33076-2113
US

IV. Provider business mailing address

11332 WILES RD
CORAL SPRINGS FL
33076-2114
US

V. Phone/Fax

Practice location:
  • Phone: 954-418-2354
  • Fax: 954-369-1440
Mailing address:
  • Phone: 954-418-2354
  • Fax: 954-369-1440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN 18968
License Number StateFL

VIII. Authorized Official

Name: DR. PRATHIMA KRISHNA ADUSUMILLI
Title or Position: OWNER
Credential: DMD, MS
Phone: 561-212-3119