Provider Demographics
NPI:1770388571
Name:KANTA, SRAVANTHI
Entity type:Individual
Prefix:
First Name:SRAVANTHI
Middle Name:
Last Name:KANTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S 40TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-6030
Mailing Address - Country:US
Mailing Address - Phone:215-573-2588
Mailing Address - Fax:
Practice Address - Street 1:13127 KINGS LAKE DR UNIT 101
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-3958
Practice Address - Country:US
Practice Address - Phone:813-677-3047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLDN308311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program