Provider Demographics
NPI:1326278300
Name:GUDURU, SAI V
Entity Type:Individual
Prefix:
First Name:SAI
Middle Name:V
Last Name:GUDURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:430 W ERIE ST
Mailing Address - Street 2:STE 200
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-6914
Mailing Address - Country:US
Mailing Address - Phone:312-274-0308
Mailing Address - Fax:312-944-9499
Practice Address - Street 1:3867 UNION DEPOSIT RD
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-5920
Practice Address - Country:US
Practice Address - Phone:717-558-0042
Practice Address - Fax:717-558-0244
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0380161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice