Provider Demographics
NPI:1821403403
Name:RENKUNTLA, RUPESHWAR ISHWAR
Entity Type:Individual
Prefix:
First Name:RUPESHWAR
Middle Name:ISHWAR
Last Name:RENKUNTLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4108 LASSEN LN
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-1248
Mailing Address - Country:US
Mailing Address - Phone:405-881-4752
Mailing Address - Fax:
Practice Address - Street 1:240 S SAGINAW BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:TX
Practice Address - Zip Code:76179-1672
Practice Address - Country:US
Practice Address - Phone:817-989-2832
Practice Address - Fax:817-989-2813
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6605122300000X
TX31354122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist