Provider Demographics
NPI:1073049623
Name:INDRAKANTI, SHYAM SUNDER (DDS, MD)
Entity Type:Individual
Prefix:
First Name:SHYAM SUNDER
Middle Name:
Last Name:INDRAKANTI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2762 N GALLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4859
Mailing Address - Country:US
Mailing Address - Phone:972-698-8500
Mailing Address - Fax:
Practice Address - Street 1:2762 N GALLOWAY AVE STE 100
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4859
Practice Address - Country:US
Practice Address - Phone:972-698-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX383051223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery