Provider Demographics
NPI:1295013514
Name:SUNDARAGOPAL, NISHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:NISHA
Middle Name:
Last Name:SUNDARAGOPAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:NISHA
Other - Middle Name:
Other - Last Name:SUNDARAGOPAL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11767 KATY FWY
Mailing Address - Street 2:STE 505
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-1768
Mailing Address - Country:US
Mailing Address - Phone:281-679-9340
Mailing Address - Fax:
Practice Address - Street 1:5300 SAN DARIO AVE
Practice Address - Street 2:#C2
Practice Address - City:LAREDO
Practice Address - State:TX
Practice Address - Zip Code:78041-3000
Practice Address - Country:US
Practice Address - Phone:956-723-6568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX273031223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes1223P0221XDental ProvidersDentistPediatric Dentistry