Provider Demographics
NPI:1942576319
Name:MOOLA, SIREESHA R (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIREESHA
Middle Name:R
Last Name:MOOLA
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 1:409 DRY GULCH BND
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-3172
Mailing Address - Country:US
Mailing Address - Phone:650-245-7009
Mailing Address - Fax:
Practice Address - Street 1:409 DRY GULCH BND
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3172
Practice Address - Country:US
Practice Address - Phone:650-245-7009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA611931223G0001X
TX278081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX261090724Medicaid