Healthcare Provider Details

I. General information

NPI: 1700080793
Provider Name (Legal Business Name): PRAVEEN REDDY GUDIPATI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PRAVEEN REDDY GUDIPATI DMD

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5770 BETHELVIEW RD STE 700E
CUMMING GA
30040-0901
US

IV. Provider business mailing address

2705 AZALEA BLUFF DR
CUMMING GA
30041-3207
US

V. Phone/Fax

Practice location:
  • Phone: 770-205-0466
  • Fax:
Mailing address:
  • Phone: 404-966-7766
  • Fax: 770-279-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN013554
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: