Provider Demographics
NPI:1639361538
Name:MUTYALA, SUBASH (DDS)
Entity Type:Individual
Prefix:
First Name:SUBASH
Middle Name:
Last Name:MUTYALA
Suffix:
Gender:M
Credentials:DDS
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1500 A W GRIMES BLVD
Mailing Address - Street 2:STE 130
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78664-7836
Mailing Address - Country:US
Mailing Address - Phone:512-238-7300
Mailing Address - Fax:512-238-7301
Practice Address - Street 1:1500 A W GRIMES BLVD
Practice Address - Street 2:STE 130
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7836
Practice Address - Country:US
Practice Address - Phone:512-238-7300
Practice Address - Fax:512-238-7301
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TX234361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry