MEDICARE: DR. HIMABINDU GOGENENI DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12013496A	IN

General Provider Information

NPI Number	:	1023615796
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HIMABINDU GOGENENI DDS

Provider Business Mailing Address
First Line	:	804 BLAKE ST APT A
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-2978
Country	:	US
Telephone Number	:	216-556-2844
Fax Number	:

Provider Business Practice Location Address
First Line	:	3575 PORTAGE AVE STE A
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-6092
Country	:	US
Telephone Number	:	574-349-2073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2020
Last Update Date	:	10/06/2020

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