Healthcare Provider Details

I. General information

NPI: 1487500187
Provider Name (Legal Business Name): GOPALA KRISHNA GANTA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2615 S CENTER ST
MARSHALLTOWN IA
50158-4501
US

IV. Provider business mailing address

1106 MAIDEN LANE CT APT 111
ANN ARBOR MI
48105-1976
US

V. Phone/Fax

Practice location:
  • Phone: 641-352-7180
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS-10460
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: