=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477800225
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIREESHA PERUMALLA D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2012
-----------------------------------------------------
Last Update Date | 03/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1813 SW FAIRLAWN RD
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66604-3646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-272-9443
-----------------------------------------------------
Fax | 785-228-9071
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1813 SW FAIRLAWN RD
-----------------------------------------------------
City | TOPEKA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66604-3646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-272-9443
-----------------------------------------------------
Fax | 785-228-9071
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 019029203
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 61308
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------