Provider Demographics
NPI:1225574312
Name:PANTHULA, PRIYANKA (DDS)
Entity type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:PANTHULA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4309 BRIDLE RUN DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-7428
Mailing Address - Country:US
Mailing Address - Phone:812-241-0837
Mailing Address - Fax:
Practice Address - Street 1:4309 BRIDLE RUN DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-7428
Practice Address - Country:US
Practice Address - Phone:812-241-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-12
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1857490122300000X
NC13440122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist