Provider Demographics
NPI:1083801880
Name:YENUGANTI, JEEVAN KUMAR (BDS, MSPH)
Entity type:Individual
Prefix:DR
First Name:JEEVAN
Middle Name:KUMAR
Last Name:YENUGANTI
Suffix:
Gender:M
Credentials:BDS, MSPH
Other - Prefix:DR
Other - First Name:JEEVAN
Other - Middle Name:K
Other - Last Name:YENUGANTI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ORAL MEDICINE & GPR
Mailing Address - Street 1:2357 ORMOND BLVD
Mailing Address - Street 2:
Mailing Address - City:DESTREHAN
Mailing Address - State:LA
Mailing Address - Zip Code:70047-2103
Mailing Address - Country:US
Mailing Address - Phone:504-638-8466
Mailing Address - Fax:
Practice Address - Street 1:30575 OLD BATON ROUGE HWY
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403
Practice Address - Country:US
Practice Address - Phone:225-306-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA64211223G0001X
LAP 1051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA034897OtherCDS
LA1864218Medicaid
LAFY4718497OtherDEA
LAFY0564561OtherDEA
LA1864218Medicaid