Healthcare Provider Details

I. General information

NPI: 1710354881
Provider Name (Legal Business Name): SRIVIDYA VULUGUNDAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2015
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4122 ROWAN RD
NEW PORT RICHEY FL
34653
US

IV. Provider business mailing address

9319 MANGROVE CT
TAMPA FL
33647-3356
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-6943
  • Fax:
Mailing address:
  • Phone: 571-294-8153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN21350
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: