Provider Demographics
NPI:1932308673
Name:GOTTAM, SUGUNA (DDS)
Entity Type:Individual
Prefix:
First Name:SUGUNA
Middle Name:
Last Name:GOTTAM
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 1:10611 FAULKNER PT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063-5429
Mailing Address - Country:US
Mailing Address - Phone:858-231-0299
Mailing Address - Fax:
Practice Address - Street 1:8849 N TARRANT PKWY
Practice Address - Street 2:SUITE 105
Practice Address - City:NORTH RICHLAND HILLS
Practice Address - State:TX
Practice Address - Zip Code:76182-7695
Practice Address - Country:US
Practice Address - Phone:858-231-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0372791223G0001X
TX234601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice