Provider Demographics
NPI:1295566628
Name:BANURU SHETTY DENTAL GROUP, P.L.L.C
Entity type:Organization
Organization Name:BANURU SHETTY DENTAL GROUP, P.L.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:VASUDHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BANURU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:201-336-0434
Mailing Address - Street 1:7727 FLYING CLOUD DR
Mailing Address - Street 2:
Mailing Address - City:EDEN PRAIRIE
Mailing Address - State:MN
Mailing Address - Zip Code:55344-3708
Mailing Address - Country:US
Mailing Address - Phone:201-336-0434
Mailing Address - Fax:
Practice Address - Street 1:7727 FLYING CLOUD DR
Practice Address - Street 2:
Practice Address - City:EDEN PRAIRIE
Practice Address - State:MN
Practice Address - Zip Code:55344-3708
Practice Address - Country:US
Practice Address - Phone:201-336-0434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty