=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710041868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LAVANYA INAMPUDI D.M.D
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2006
-----------------------------------------------------
Last Update Date | 02/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 655 WEST ILLINOIS AVENUE SUITE # 1065
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-943-2484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 655 WEST ILLINOIS AVE #1065
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-943-2484
-----------------------------------------------------
Fax | 214-975-4811
-----------------------------------------------------
=====================================================
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 | 22252
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------