Provider Demographics
NPI:1568763605
Name:SATISH K GOTTUMUKKULA DMD LTD
Entity Type:Organization
Organization Name:SATISH K GOTTUMUKKULA DMD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSOCIATE
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTHAPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-803-6431
Mailing Address - Street 1:1940 W GALENA BLVD
Mailing Address - Street 2:STE #8
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-4319
Mailing Address - Country:US
Mailing Address - Phone:630-892-2193
Mailing Address - Fax:630-892-3563
Practice Address - Street 1:1940 W GALENA BLVD
Practice Address - Street 2:STE #8
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60506-4319
Practice Address - Country:US
Practice Address - Phone:630-892-2193
Practice Address - Fax:630-892-3563
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-05
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190266121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty