Provider Demographics
NPI:1215423819
Name:EDPUGANTI, SUDHA M
Entity type:Individual
Prefix:
First Name:SUDHA
Middle Name:M
Last Name:EDPUGANTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 GRAND OAK DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0346
Mailing Address - Country:US
Mailing Address - Phone:980-226-8891
Mailing Address - Fax:
Practice Address - Street 1:8020 NORTHLAKE CREEK DR STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-4487
Practice Address - Country:US
Practice Address - Phone:704-264-1441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92731223G0001X
NC11112122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice