MEDICARE: GOGINENI DENTAL

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1114858776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOGINENI DENTAL

Provider Business Mailing Address
First Line	:	1322 S PRAIRIE AVE UNIT 1001
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60605-3074
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	210 N PINE ST
Second Line	:
City	:	NEW LENOX
State	:	IL
Zip	:	60451-1757
Country	:	US
Telephone Number	:	815-485-8252
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	SIRISHA GOGINENI
Credential	:	DDS
Telephone Number	:	847-899-9517

Provider Enumeration Date	:	05/25/2026
Last Update Date	:	05/25/2026

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Directions to “GOGINENI DENTAL ” Practice Location

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