Provider Demographics
NPI:1164778080
Name:BOYAPATI, YASODA VARDHANI (DDS)
Entity Type:Individual
Prefix:DR
First Name:YASODA VARDHANI
Middle Name:
Last Name:BOYAPATI
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 1:1000 FM 300
Mailing Address - Street 2:
Mailing Address - City:LEVELLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79336-6235
Mailing Address - Country:US
Mailing Address - Phone:806-894-7842
Mailing Address - Fax:806-894-3378
Practice Address - Street 1:1300 S GREGG ST
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-4325
Practice Address - Country:US
Practice Address - Phone:432-517-4557
Practice Address - Fax:432-517-4556
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX283101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX281971602Medicaid