Healthcare Provider Details

I. General information

NPI: 1790053908
Provider Name (Legal Business Name): ANIL K GUDIPATI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2011
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 FM 423 STE 100
LITTLE ELM TX
75068-6705
US

IV. Provider business mailing address

3010 FM 423 STE 100
LITTLE ELM TX
75068-6705
US

V. Phone/Fax

Practice location:
  • Phone: 469-239-0123
  • Fax: 469-213-1524
Mailing address:
  • Phone: 469-239-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number29622
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: