Provider Demographics
NPI:1487190906
Name:THATISHETTY, ANUSHA GANTA (DDS)
Entity Type:Individual
Prefix:
First Name:ANUSHA
Middle Name:GANTA
Last Name:THATISHETTY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ANUSHA
Other - Middle Name:
Other - Last Name:GANTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4338 NORMANDY AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-2042
Mailing Address - Country:US
Mailing Address - Phone:912-704-1980
Mailing Address - Fax:
Practice Address - Street 1:3030 LBJ FWY STE 1400
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-2766
Practice Address - Country:US
Practice Address - Phone:972-663-5314
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02659900122300000X
TX32839122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist