Healthcare Provider Details

I. General information

NPI: 1538510698
Provider Name (Legal Business Name): SRINIVAS PUSHPALA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2016
Last Update Date: 08/24/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 SPRING STUEBNER RD STE 700
SPRING TX
77389-5197
US

IV. Provider business mailing address

6710 SPRING STUEBNER RD STE 700
SPRING TX
77389-5197
US

V. Phone/Fax

Practice location:
  • Phone: 281-791-0043
  • Fax:
Mailing address:
  • Phone: 281-791-0043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number32852
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number32852
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: