Healthcare Provider Details

I. General information

NPI: 1770847436
Provider Name (Legal Business Name): NISHANTH REDDY PUCHALAPALLI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2012
Last Update Date: 08/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 N MAIN AVE
LOVINGTON NM
88260-3417
US

IV. Provider business mailing address

701 N MAIN AVE
LOVINGTON NM
88260-3417
US

V. Phone/Fax

Practice location:
  • Phone: 408-306-8365
  • Fax:
Mailing address:
  • Phone: 408-306-8365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD 3837
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD 3837
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: