=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679704076
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANJUSHA TUMMALA DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/03/2009
-----------------------------------------------------
Last Update Date | 10/15/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6500 DENTON HWY STE B1
-----------------------------------------------------
City | WATAUGA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76148-2526
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-428-4005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 654 BANBURY RD
-----------------------------------------------------
City | COPPELL
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75019-2063
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 848-391-6885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 24902
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------