Provider Demographics
NPI:1336480524
Name:GANGULY, AMRITA (DDS)
Entity Type:Individual
Prefix:DR
First Name:AMRITA
Middle Name:
Last Name:GANGULY
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 1:809 S DAMEN AVE
Mailing Address - Street 2:APT-904A
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3858
Mailing Address - Country:US
Mailing Address - Phone:970-324-3871
Mailing Address - Fax:
Practice Address - Street 1:846 W 17TH ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77008-3528
Practice Address - Country:US
Practice Address - Phone:310-292-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29875122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist