Provider Demographics
NPI:1568519650
Name:GOWDA, SHANTALA
Entity Type:Individual
Prefix:DR
First Name:SHANTALA
Middle Name:
Last Name:GOWDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 LITTLE NECK ROAD
Mailing Address - Street 2:B LDG. 3400 STE. 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452
Mailing Address - Country:US
Mailing Address - Phone:757-498-5142
Mailing Address - Fax:757-498-3710
Practice Address - Street 1:397 LITTLE NECK RD
Practice Address - Street 2:BLDG. 3400 STE. 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-5765
Practice Address - Country:US
Practice Address - Phone:757-498-5142
Practice Address - Fax:757-498-3710
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice