Provider Demographics
NPI:1093164899
Name:GUNTUPALLI, NAGA TARUN
Entity Type:Individual
Prefix:DR
First Name:NAGA TARUN
Middle Name:
Last Name:GUNTUPALLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 W CLAIREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6123
Mailing Address - Country:US
Mailing Address - Phone:251-635-6017
Mailing Address - Fax:
Practice Address - Street 1:1002 W CLAIREMONT AVE
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6123
Practice Address - Country:US
Practice Address - Phone:251-635-6017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI1001389-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program