Provider Demographics
NPI:1104479724
Name:GONUGUNTLA KAMMA, PRAVEEN KUMAR (DMD)
Entity type:Individual
Prefix:
First Name:PRAVEEN KUMAR
Middle Name:
Last Name:GONUGUNTLA KAMMA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 WOLF RANCH PKWY APT 3213
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-7289
Mailing Address - Country:US
Mailing Address - Phone:502-999-6322
Mailing Address - Fax:
Practice Address - Street 1:3650 W STAN SCHLUETER LOOP STE 160
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76549-6814
Practice Address - Country:US
Practice Address - Phone:254-699-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX355191223G0001X
IL0190328261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice