Healthcare Provider Details

I. General information

NPI: 1992622849
Provider Name (Legal Business Name): MOUNIKA GADIRAJU DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

611 W PARK ST
URBANA IL
61801-2529
US

IV. Provider business mailing address

1710 GENTRY SQUARE LN APT 207
CHAMPAIGN IL
61821-5977
US

V. Phone/Fax

Practice location:
  • Phone: 217-383-3311
  • Fax:
Mailing address:
  • Phone: 224-634-7557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number018.012598
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: