Provider Demographics
NPI:1770870347
Name:PANGULURI, SREENIVASULU (DMD)
Entity type:Individual
Prefix:DR
First Name:SREENIVASULU
Middle Name:
Last Name:PANGULURI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 NORTHAMPTON ST
Mailing Address - Street 2:APT#2304
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4014
Mailing Address - Country:US
Mailing Address - Phone:419-819-7349
Mailing Address - Fax:
Practice Address - Street 1:21 MONTAUK AVE
Practice Address - Street 2:#102
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4906
Practice Address - Country:US
Practice Address - Phone:860-444-9345
Practice Address - Fax:860-443-0432
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2011-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010544122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist