Provider Demographics
NPI:1013527035
Name:CHOUGULE, KETAKI (DDS)
Entity Type:Individual
Prefix:
First Name:KETAKI
Middle Name:
Last Name:CHOUGULE
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 1:901 E FM 700 APT 615
Mailing Address - Street 2:
Mailing Address - City:BIG SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:79720-5773
Mailing Address - Country:US
Mailing Address - Phone:510-203-9391
Mailing Address - Fax:
Practice Address - Street 1:1915 S GREGG ST
Practice Address - Street 2:
Practice Address - City:BIG SPRING
Practice Address - State:TX
Practice Address - Zip Code:79720-5434
Practice Address - Country:US
Practice Address - Phone:432-264-0205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36467122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist