Provider Demographics
NPI:1720647092
Name:AGGARWAL, TIRUMALA (DMD)
Entity Type:Individual
Prefix:
First Name:TIRUMALA
Middle Name:
Last Name:AGGARWAL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2655 SHOWPLACE DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-3334
Mailing Address - Country:US
Mailing Address - Phone:860-595-8906
Mailing Address - Fax:
Practice Address - Street 1:6100 WASHINGTON AVE STE F2
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4000
Practice Address - Country:US
Practice Address - Phone:262-999-9998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0322791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100189811Medicaid