Healthcare Provider Details

I. General information

NPI: 1114858776
Provider Name (Legal Business Name): GOGINENI DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2026
Last Update Date: 05/25/2026
Certification Date: 05/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 N PINE ST
NEW LENOX IL
60451-1757
US

IV. Provider business mailing address

1322 S PRAIRIE AVE UNIT 1001
CHICAGO IL
60605-3074
US

V. Phone/Fax

Practice location:
  • Phone: 815-485-8252
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SIRISHA GOGINENI
Title or Position: DENTIST
Credential: DDS
Phone: 847-899-9517