Provider Demographics
NPI:1538510698
Name:PUSHPALA, SRINIVAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:
Last Name:PUSHPALA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6710 SPRING STUEBNER RD STE 700
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-5197
Mailing Address - Country:US
Mailing Address - Phone:281-791-0043
Mailing Address - Fax:
Practice Address - Street 1:6710 SPRING STUEBNER RD STE 700
Practice Address - Street 2:
Practice Address - City:SPRING
Practice Address - State:TX
Practice Address - Zip Code:77389-5197
Practice Address - Country:US
Practice Address - Phone:281-791-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-29
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX328521223E0200X, 1223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice