Provider Demographics
NPI:1851065296
Name:CEGU PHANI RAJ, PRAKRUTHI (DDS)
Entity Type:Individual
Prefix:
First Name:PRAKRUTHI
Middle Name:
Last Name:CEGU PHANI RAJ
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9199 TRYON CV
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-2946
Mailing Address - Country:US
Mailing Address - Phone:901-857-5640
Mailing Address - Fax:
Practice Address - Street 1:440 W SAM RIDLEY PKWY STE 140
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-2999
Practice Address - Country:US
Practice Address - Phone:615-768-3242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-08
Last Update Date:2021-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN116761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice