Provider Demographics
NPI:1326394479
Name:MUPPALLA, PRATYUSHA (DDS)
Entity Type:Individual
Prefix:
First Name:PRATYUSHA
Middle Name:
Last Name:MUPPALLA
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 1:2050 E ALGONQUIN RD
Mailing Address - Street 2:SUITE 610
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4144
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:847-496-7603
Practice Address - Street 1:542 W DUNDEE RD
Practice Address - Street 2:SUITE B
Practice Address - City:WHEELING
Practice Address - State:IL
Practice Address - Zip Code:60090-3227
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-7603
Is Sole Proprietor?:No
Enumeration Date:2012-07-26
Last Update Date:2012-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0291641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice