Provider Demographics
NPI:1508008855
Name:GANTI, AJAY (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:AJAY
Middle Name:
Last Name:GANTI
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 W FM 544 STE 240
Mailing Address - Street 2:
Mailing Address - City:WYLIE
Mailing Address - State:TX
Mailing Address - Zip Code:75098-4931
Mailing Address - Country:US
Mailing Address - Phone:469-596-7722
Mailing Address - Fax:469-596-7720
Practice Address - Street 1:2300 W FM 544 STE 240
Practice Address - Street 2:
Practice Address - City:WYLIE
Practice Address - State:TX
Practice Address - Zip Code:75098-4931
Practice Address - Country:US
Practice Address - Phone:469-596-7722
Practice Address - Fax:469-596-7720
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX350331223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1033759584Medicaid
TX1508008855Medicaid