Healthcare Provider Details

I. General information

NPI: 1093423667
Provider Name (Legal Business Name): ANKITA GUMMADI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2022
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 S LARKIN AVE
JOLIET IL
60436-1243
US

IV. Provider business mailing address

14710 S WALLIN DR STE 207
PLAINFIELD IL
60544-2520
US

V. Phone/Fax

Practice location:
  • Phone: 815-773-6200
  • Fax:
Mailing address:
  • Phone: 630-207-7624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019034053
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: