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General NPI Number Information
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NPI Number | 1902447899
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Entity Type | Individual
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Provider Name | SHANTHALA GOWDARA SRINIVASA REDDY
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Gender | Female
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Dates
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Enumeration Date | 10/02/2019
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Last Update Date | 12/25/2024
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Provider Practice Location Address
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Address Line | 1001 US HIGHWAY 377 S STE 107
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City | AUBREY
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State | TX
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Zip | 76227-5658
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Country | US
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Telephone | 940-202-0670
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Fax |
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Provider Business Mailing Address
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Address Line | 3718 PLATTE RIVER TRL
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City | PROSPER
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State | TX
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Zip | 75078-2696
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Country | US
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Telephone | 407-227-0000
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 35665
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License Number State | TX
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