Provider Demographics
NPI:1902447899
Name:GOWDARA SRINIVASA REDDY, SHANTHALA
Entity type:Individual
Prefix:
First Name:SHANTHALA
Middle Name:
Last Name:GOWDARA SRINIVASA REDDY
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 1:3718 PLATTE RIVER TRL
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-2696
Mailing Address - Country:US
Mailing Address - Phone:407-227-0000
Mailing Address - Fax:
Practice Address - Street 1:1001 US HIGHWAY 377 S STE 107
Practice Address - Street 2:
Practice Address - City:AUBREY
Practice Address - State:TX
Practice Address - Zip Code:76227-5658
Practice Address - Country:US
Practice Address - Phone:940-202-0670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice