Healthcare Provider Details

I. General information

NPI: 1518703495
Provider Name (Legal Business Name): SRITEJA GUMMADI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W WALL ST
MORRISON IL
61270-2139
US

IV. Provider business mailing address

3911 53RD AVE
BETTENDORF IA
52722-1226
US

V. Phone/Fax

Practice location:
  • Phone: 815-400-9141
  • Fax:
Mailing address:
  • Phone: 512-818-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7936
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: