Provider Demographics
NPI:1093193484
Name:BHAGAVATULA, GARGI (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARGI
Middle Name:
Last Name:BHAGAVATULA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 N SHORELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEFISH BAY
Mailing Address - State:WI
Mailing Address - Zip Code:53217-4661
Mailing Address - Country:US
Mailing Address - Phone:402-213-6077
Mailing Address - Fax:
Practice Address - Street 1:6048 W MEQUON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-1938
Practice Address - Country:US
Practice Address - Phone:402-213-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10010311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice