Healthcare Provider Details

I. General information

NPI: 1932884160
Provider Name (Legal Business Name): LAKSHMI SRAVYA RALLABANDI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E BROADWAY ST
BOLIVAR MO
65613-1623
US

IV. Provider business mailing address

203 E BROADWAY ST
BOLIVAR MO
65613-1623
US

V. Phone/Fax

Practice location:
  • Phone: 417-328-6334
  • Fax: 417-326-8111
Mailing address:
  • Phone: 417-328-6334
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2024014443
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: