Provider Demographics
NPI:1407045735
Name:GAJAPATHI, SHARAVANA KUMAR (DDS, MPH)
Entity Type:Individual
Prefix:DR
First Name:SHARAVANA KUMAR
Middle Name:
Last Name:GAJAPATHI
Suffix:
Gender:M
Credentials:DDS, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1115 US HIGHWAY 259 S
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TX
Mailing Address - Zip Code:75654-3629
Mailing Address - Country:US
Mailing Address - Phone:903-392-8251
Mailing Address - Fax:903-392-8207
Practice Address - Street 1:1115 US HIGHWAY 259 S
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75654-3629
Practice Address - Country:US
Practice Address - Phone:903-392-8251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24289122300000X, 1223P0221X
MND12360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX206661513Medicaid
TX203375501Medicaid
TX206661513Medicaid