Provider Demographics
NPI:1407284128
Name:GANTAYAT, SANGEETA SANJAYKUMAR (DMD)
Entity Type:Individual
Prefix:
First Name:SANGEETA
Middle Name:SANJAYKUMAR
Last Name:GANTAYAT
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:463 WESTFIELD BLVD APT 1024
Mailing Address - Street 2:
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76502-5324
Mailing Address - Country:US
Mailing Address - Phone:201-696-1807
Mailing Address - Fax:
Practice Address - Street 1:4215 FRANKLIN AVE STE 300
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-6903
Practice Address - Country:US
Practice Address - Phone:254-227-6444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039773122300000X
TX30630122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist