Provider Demographics
NPI:1518367945
Name:PURUSHOTHAMAN, UMAMAGESHWARI (DMD)
Entity Type:Individual
Prefix:DR
First Name:UMAMAGESHWARI
Middle Name:
Last Name:PURUSHOTHAMAN
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 1:11613 SANTA ELENA LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-5077
Mailing Address - Country:US
Mailing Address - Phone:978-328-4920
Mailing Address - Fax:
Practice Address - Street 1:500 W WHITESTONE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-2271
Practice Address - Country:US
Practice Address - Phone:512-528-5454
Practice Address - Fax:512-528-5455
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No122300000XDental ProvidersDentist