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 1:770 FAIRWAY DR APT 2217
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-6793
Mailing Address - Country:US
Mailing Address - Phone:407-227-0000
Mailing Address - Fax:
Practice Address - Street 1:3720 CALL FIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76308-2766
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:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX356651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice