Healthcare Provider Details

I. General information

NPI: 1265084875
Provider Name (Legal Business Name): VENKATA SIVA REDDY GUVVA BDS,PROSTHODONTICS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2019
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3306 EMERALD LN
JEFFERSON CITY MO
65109-6880
US

IV. Provider business mailing address

3625 BRIARMONT AVE APT 101
COLUMBIA MO
65201-3680
US

V. Phone/Fax

Practice location:
  • Phone: 573-634-2222
  • Fax:
Mailing address:
  • Phone: 419-819-7450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2020036528
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: