=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114816477
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PRIDHVI GADIRAJU DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2025
-----------------------------------------------------
Last Update Date | 07/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 165 KANDEMOR LN
-----------------------------------------------------
City | ROCKY MOUNT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27804-3212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-443-6443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1013 GROGANS MILL DR
-----------------------------------------------------
City | CARY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27519-7193
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 571-340-4920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 14292
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------