Provider Demographics
NPI:1700080793
Name:GUDIPATI, PRAVEEN REDDY (DMD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:REDDY
Last Name:GUDIPATI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:PRAVEEN
Other - Middle Name:REDDY
Other - Last Name:GUDIPATI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:2705 AZALEA BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-3207
Mailing Address - Country:US
Mailing Address - Phone:404-966-7766
Mailing Address - Fax:770-279-1222
Practice Address - Street 1:3993 LAWRENCEVILLE HWY NW
Practice Address - Street 2:100 A
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2897
Practice Address - Country:US
Practice Address - Phone:770-279-2020
Practice Address - Fax:770-279-1222
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013554122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist