Healthcare Provider Details

I. General information

NPI: 1972764967
Provider Name (Legal Business Name): SRAVANTHI GANNE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1728 DUNLAWTON AVE STE 3 APARTMENT 2G
PORT ORANGE FL
32127-2923
US

IV. Provider business mailing address

1728 DUNLAWTON AVE STE 3
PORT ORANGE FL
32127-2923
US

V. Phone/Fax

Practice location:
  • Phone: 412-913-8877
  • Fax: 844-704-4268
Mailing address:
  • Phone: 412-913-8877
  • Fax: 844-704-4268

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN19304
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: