Healthcare Provider Details

I. General information

NPI: 1376942904
Provider Name (Legal Business Name): KRISHNAVENI GUTTIKONDA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2014
Last Update Date: 09/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1998 N MOTEL BLVD
LAS CRUCES NM
88007-4100
US

IV. Provider business mailing address

PO BOX 370
HATCH NM
87937-0370
US

V. Phone/Fax

Practice location:
  • Phone: 575-541-5941
  • Fax: 575-541-5048
Mailing address:
  • Phone: 575-267-3280
  • Fax: 575-267-1747

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number30408
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD4341
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: