MEDICARE: SUGUNA GOTTAM 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	1223G0001X	General Practice Dentistry	DS037279	PA
2	1223G0001X	General Practice Dentistry	23460	TX

General Provider Information

NPI Number	:	1932308673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUGUNA GOTTAM DDS

Provider Business Mailing Address
First Line	:	10611 FAULKNER PT
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063-5429
Country	:	US
Telephone Number	:	858-231-0299
Fax Number	:

Provider Business Practice Location Address
First Line	:	8849 N TARRANT PKWY
Second Line	:	SUITE 105
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76182-7695
Country	:	US
Telephone Number	:	858-231-0299
Fax Number	:

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

Provider Enumeration Date	:	07/12/2007
Last Update Date	:	05/22/2012

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