Provider Demographics
NPI:1760704944
Name:SUBASH MUTYALA, P.A.
Entity Type:Organization
Organization Name:SUBASH MUTYALA, P.A.
Other - Org Name:LITTLE EXPLORERS PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBASH
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTYALA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:512-238-7300
Mailing Address - Street 1:1500 A W GRIMES BLVD
Mailing Address - Street 2:
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:
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-16
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX234361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty