Healthcare Provider Details

I. General information

NPI: 1487147781
Provider Name (Legal Business Name): DR. VAISHNAVI GUMMADI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2018
Last Update Date: 06/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4898 LITTLE RD
ARLINGTON TX
76017-1054
US

IV. Provider business mailing address

1103 W 30TH ST APT 3
LOS ANGELES CA
90007-5336
US

V. Phone/Fax

Practice location:
  • Phone: 817-672-0034
  • Fax:
Mailing address:
  • Phone: 804-551-0572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number34150
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: