=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326856105
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANKITHA PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/25/2024
-----------------------------------------------------
Last Update Date | 12/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 E ELDORADO PKWY STE 101
-----------------------------------------------------
City | LITTLE ELM
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75068-5112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-227-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3718 PLATTE RIVER TRL
-----------------------------------------------------
City | PROSPER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75078-2696
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-227-0000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | GENERAL DENTIST
-----------------------------------------------------
Name | DR. SHANTHALA GOWDARA SRINIVASA REDDY
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 407-227-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------