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General NPI Number Information
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NPI Number | 1730749888
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Entity Type | Individual
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Provider Name | KALYANA CHAKRAVARTHI PONANGI DMD
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Gender | Male
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Dates
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Enumeration Date | 06/19/2019
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Last Update Date | 05/10/2024
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Provider Practice Location Address
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Address Line | 651 E CROCKETT ST
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City | LULING
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State | TX
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Zip | 78648-2602
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Country | US
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Telephone | 830-875-6603
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Fax |
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Provider Business Mailing Address
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Address Line | 11708 JOHNNY WEISMULLER LN
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City | AUSTIN
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State | TX
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Zip | 78748-2975
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Country | US
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Telephone | 929-393-5626
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 39423
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License Number State | TX
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