Healthcare Provider Details

I. General information

NPI: 1649040619
Provider Name (Legal Business Name): SHARASCHANDRA REDDY GOVINDOOL BDS, MDS, MSC, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/02/2024
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W MICHIGAN ST
INDIANAPOLIS IN
46202-5211
US

IV. Provider business mailing address

1 CAMBRIDGE SQ APT A
WILLIAMSVILLE NY
14221-4822
US

V. Phone/Fax

Practice location:
  • Phone: 571-685-0161
  • Fax: 317-274-7433
Mailing address:
  • Phone: 571-685-0161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number12014343B
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: