Healthcare Provider Details

I. General information

NPI: 1518703495
Provider Name (Legal Business Name): SRITEJA GUMMADI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 N STONEWALL AVE FL 4
OKLAHOMA CITY OK
73117-1214
US

IV. Provider business mailing address

8705 KEN AARON CT
AUSTIN TX
78717-5489
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-5714
  • Fax:
Mailing address:
  • Phone: 512-818-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7936
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: