Provider Demographics
NPI:1316042690
Name:GOTTUMUKKULA, SATISH K (DMD)
Entity Type:Individual
Prefix:
First Name:SATISH
Middle Name:K
Last Name:GOTTUMUKKULA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 W GALENA BLVD
Mailing Address - Street 2:STE 8
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506
Mailing Address - Country:US
Mailing Address - Phone:630-892-2193
Mailing Address - Fax:630-892-3563
Practice Address - Street 1:1940 W GALENA BLVD
Practice Address - Street 2:STE 8
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506
Practice Address - Country:US
Practice Address - Phone:630-892-2193
Practice Address - Fax:630-892-3563
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice