Healthcare Provider Details

I. General information

NPI: 1548908536
Provider Name (Legal Business Name): KAANTI GOWRU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2022
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9111 W 151ST ST
ORLAND PARK IL
60462-3202
US

IV. Provider business mailing address

9111 W 151ST ST
ORLAND PARK IL
60462-3202
US

V. Phone/Fax

Practice location:
  • Phone: 408-440-6440
  • Fax:
Mailing address:
  • Phone: 708-590-4422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2951000878
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number021.003316
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: