Healthcare Provider Details

I. General information

NPI: 1558229195
Provider Name (Legal Business Name): MOUNICA REDDY GAYAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6111 S CEDAR ST
LANSING MI
48911-5714
US

IV. Provider business mailing address

813 ARUNDELL DR
HOWELL MI
48843-7210
US

V. Phone/Fax

Practice location:
  • Phone: 517-393-3447
  • Fax:
Mailing address:
  • Phone: 734-747-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2901603114
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: