Provider Demographics
NPI:1376953471
Name:COLLURU, PRIYA VINOTHINI
Entity Type:Individual
Prefix:DR
First Name:PRIYA
Middle Name:VINOTHINI
Last Name:COLLURU
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 1:3913, WHEELER'S STREET
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76111
Mailing Address - Country:US
Mailing Address - Phone:682-747-0111
Mailing Address - Fax:504-941-8170
Practice Address - Street 1:3913, WHEELER'S STREET
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111
Practice Address - Country:US
Practice Address - Phone:682-747-0111
Practice Address - Fax:504-941-8170
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAS-7141223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics