Provider Demographics
NPI:1295177012
Name:KORUPOLU, RISHANK REDDY (DDS)
Entity type:Individual
Prefix:DR
First Name:RISHANK
Middle Name:REDDY
Last Name:KORUPOLU
Suffix:
Gender:M
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:PO BOX 15781
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34604-0124
Mailing Address - Country:US
Mailing Address - Phone:352-346-7989
Mailing Address - Fax:352-799-3214
Practice Address - Street 1:3052 N EASTMAN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5093
Practice Address - Country:US
Practice Address - Phone:903-663-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-22
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29361122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist