Provider Demographics
NPI:1700498722
Name:VELLATURI, SRAVANA JYOTHI
Entity Type:Individual
Prefix:
First Name:SRAVANA JYOTHI
Middle Name:
Last Name:VELLATURI
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 1:39224 GUARDINO DR APT 113
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-3018
Mailing Address - Country:US
Mailing Address - Phone:270-792-6395
Mailing Address - Fax:
Practice Address - Street 1:780 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4972
Practice Address - Country:US
Practice Address - Phone:408-796-3110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-20
Last Update Date:2020-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA105241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty