Provider Demographics
NPI:1104078906
Name:VURUGONDA, ANUPAMA
Entity type:Individual
Prefix:
First Name:ANUPAMA
Middle Name:
Last Name:VURUGONDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 ABERDEEN AVE
Mailing Address - Street 2:
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-8604
Mailing Address - Country:US
Mailing Address - Phone:616-510-0884
Mailing Address - Fax:
Practice Address - Street 1:2064 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8773
Practice Address - Country:US
Practice Address - Phone:616-475-2299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-13
Last Update Date:2008-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist