Provider Demographics
NPI:1316366180
Name:GORUGANTULA, LAKSHMI MITREYI
Entity Type:Individual
Prefix:
First Name:LAKSHMI MITREYI
Middle Name:
Last Name:GORUGANTULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 BERRY RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-0162
Mailing Address - Country:US
Mailing Address - Phone:214-460-7079
Mailing Address - Fax:
Practice Address - Street 1:13115 JOSEY LN
Practice Address - Street 2:
Practice Address - City:FARMERS BRANCH
Practice Address - State:TX
Practice Address - Zip Code:75234-6350
Practice Address - Country:US
Practice Address - Phone:972-243-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32505125Q00000X, 1223X0008X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No125Q00000XDental ProvidersOral Medicinist
No1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology