Healthcare Provider Details

I. General information

NPI: 1316560824
Provider Name (Legal Business Name): MYTHILEE KUGATHASAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 04/24/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 PEEKSKILL CT
JOHNS CREEK GA
30097-1936
US

IV. Provider business mailing address

316 PEEKSKILL CT
JOHNS CREEK GA
30097-1936
US

V. Phone/Fax

Practice location:
  • Phone: 262-490-6341
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number063423-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: