Provider Demographics
NPI:1285058420
Name:GORANTLA, BHARATHI (MDS)
Entity type:Individual
Prefix:
First Name:BHARATHI
Middle Name:
Last Name:GORANTLA
Suffix:
Gender:F
Credentials:MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3890 DIXIE HWY #1A
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48601
Mailing Address - Country:US
Mailing Address - Phone:989-777-4880
Mailing Address - Fax:
Practice Address - Street 1:3890 DIXIE HWY # 1A
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48601-4205
Practice Address - Country:US
Practice Address - Phone:989-777-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-07
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901022323122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist