Provider Demographics
NPI:1750554937
Name:DR. ASHA J VELLANKI DDS PC
Entity type:Organization
Organization Name:DR. ASHA J VELLANKI DDS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ASHA
Authorized Official - Middle Name:J
Authorized Official - Last Name:VELLANKI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:678-407-9706
Mailing Address - Street 1:1575 LAWRENCEVILLE HWY
Mailing Address - Street 2:STE G
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-4605
Mailing Address - Country:US
Mailing Address - Phone:678-407-9706
Mailing Address - Fax:678-407-9709
Practice Address - Street 1:1575 LAWRENCEVILLE HWY
Practice Address - Street 2:STE G
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-4605
Practice Address - Country:US
Practice Address - Phone:678-407-9706
Practice Address - Fax:678-407-9709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0121511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty