Provider Demographics
NPI:1477800225
Name:PERUMALLA, SIREESHA (DMD)
Entity Type:Individual
Prefix:DR
First Name:SIREESHA
Middle Name:
Last Name:PERUMALLA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:SIREESHA
Other - Middle Name:
Other - Last Name:BOGANATHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:1813 SW FAIRLAWN RD
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66604-3646
Mailing Address - Country:US
Mailing Address - Phone:785-272-9443
Mailing Address - Fax:785-228-9071
Practice Address - Street 1:1813 SW FAIRLAWN RD
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66604-3646
Practice Address - Country:US
Practice Address - Phone:785-272-9443
Practice Address - Fax:785-228-9071
Is Sole Proprietor?:No
Enumeration Date:2012-08-11
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019029203122300000X
KS613081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist