Provider Demographics
NPI:1407531775
Name:CHANDRAKUMAR, GNANIKA
Entity type:Individual
Prefix:
First Name:GNANIKA
Middle Name:
Last Name:CHANDRAKUMAR
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 1:7327 STILL HAVEN DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:TX
Mailing Address - Zip Code:77407-4981
Mailing Address - Country:US
Mailing Address - Phone:309-863-6059
Mailing Address - Fax:
Practice Address - Street 1:5501 AVENUE I
Practice Address - Street 2:
Practice Address - City:ROSENBERG
Practice Address - State:TX
Practice Address - Zip Code:77471-6141
Practice Address - Country:US
Practice Address - Phone:346-239-8871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2024-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40023122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist