Provider Demographics
NPI:1093423667
Name:GUMMADI, ANKITA
Entity Type:Individual
Prefix:
First Name:ANKITA
Middle Name:
Last Name:GUMMADI
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 1:14710 S WALLIN DR STE 207
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-2520
Mailing Address - Country:US
Mailing Address - Phone:630-207-7624
Mailing Address - Fax:
Practice Address - Street 1:10 S LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436-1243
Practice Address - Country:US
Practice Address - Phone:815-773-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-11
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019034053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist