Provider Demographics
NPI:1568670495
Name:GUTTA, RAJESH (DDS, MS)
Entity type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:GUTTA
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 W WALL ST
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-6423
Mailing Address - Country:US
Mailing Address - Phone:432-683-1863
Mailing Address - Fax:432-570-8779
Practice Address - Street 1:2003 W WALL ST
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-6423
Practice Address - Country:US
Practice Address - Phone:432-683-1863
Practice Address - Fax:432-570-8779
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2015-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX233351223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
H01622Medicare UPIN
WVWV1639AMedicare PIN
WV3810022988Medicaid