Provider Demographics
NPI:1881208478
Name:GANGAJI, POORNIMA SWAMY (DMD)
Entity Type:Individual
Prefix:DR
First Name:POORNIMA
Middle Name:SWAMY
Last Name:GANGAJI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1568 PALOMINO DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9666
Mailing Address - Country:US
Mailing Address - Phone:312-806-1895
Mailing Address - Fax:
Practice Address - Street 1:760 N, ILLINOIS RTE 59
Practice Address - Street 2:STE100
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563
Practice Address - Country:US
Practice Address - Phone:630-333-9571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.032807122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice