Provider Demographics
NPI:1730714767
Name:PATHAGUNTI, SRINIVASA REDDY (BDS, MS, MPH)
Entity type:Individual
Prefix:DR
First Name:SRINIVASA REDDY
Middle Name:
Last Name:PATHAGUNTI
Suffix:
Gender:M
Credentials:BDS, MS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7010 S ZARZAMORA ST STE 113
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78224-1148
Mailing Address - Country:US
Mailing Address - Phone:210-921-0603
Mailing Address - Fax:
Practice Address - Street 1:7010 S ZARZAMORA ST STE 113
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78224-1148
Practice Address - Country:US
Practice Address - Phone:210-921-0603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-10
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35888122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty