Provider Demographics
NPI:1245594589
Name:KONEGOWDA, VIDYAVATHI (DDS)
Entity Type:Individual
Prefix:DR
First Name:VIDYAVATHI
Middle Name:
Last Name:KONEGOWDA
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 1:1076 ARCHES PARK DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5649
Mailing Address - Country:US
Mailing Address - Phone:248-613-5147
Mailing Address - Fax:
Practice Address - Street 1:3030 LBJ FWY
Practice Address - Street 2:SUITE 1400
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-7781
Practice Address - Country:US
Practice Address - Phone:972-444-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010206981223G0001X
TX286021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice