Provider Demographics
NPI:1164084554
Name:VENNAPUSALA, PRAMEELA (DDS)
Entity Type:Individual
Prefix:
First Name:PRAMEELA
Middle Name:
Last Name:VENNAPUSALA
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 1:259 FORT COBB WAY
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-2121
Mailing Address - Country:US
Mailing Address - Phone:425-829-4738
Mailing Address - Fax:
Practice Address - Street 1:259 FORT COBB WAY
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78628-2121
Practice Address - Country:US
Practice Address - Phone:425-829-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX35352122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3211Medicaid