Provider Demographics
NPI:1629322359
Name:HAJEEBU VENKATA, GODA DEVI SUBHA (DMD)
Entity Type:Individual
Prefix:MRS
First Name:GODA DEVI SUBHA
Middle Name:
Last Name:HAJEEBU VENKATA
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 1:11606 NW 48TH ST
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33076-3525
Mailing Address - Country:US
Mailing Address - Phone:954-415-2098
Mailing Address - Fax:
Practice Address - Street 1:11606 NW48TH STREET
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33076
Practice Address - Country:US
Practice Address - Phone:954-415-2098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-02
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN19920122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist