Provider Demographics
NPI:1609375658
Name:RENUKA, SOWMYA (BDS)
Entity Type:Individual
Prefix:
First Name:SOWMYA
Middle Name:
Last Name:RENUKA
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:735 COWBOYS PKWY APT 2099
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-7733
Mailing Address - Country:US
Mailing Address - Phone:309-660-2120
Mailing Address - Fax:
Practice Address - Street 1:4200 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76115-1400
Practice Address - Country:US
Practice Address - Phone:309-660-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336661223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health