Healthcare Provider Details

I. General information

NPI: 1093409823
Provider Name (Legal Business Name): RASHMIKA REDDY NALLABOLU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2023
Last Update Date: 08/06/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

679 BALDWIN RD
CORNELIA GA
30531-5768
US

IV. Provider business mailing address

6000 AVA AVE APT 3110
GAINESVILLE GA
30504
US

V. Phone/Fax

Practice location:
  • Phone: 706-953-3669
  • Fax:
Mailing address:
  • Phone: 314-341-9325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN-123867
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: