Provider Demographics
NPI:1811159247
Name:PRAKASH, NAGASHREE BALUR (DDS)
Entity type:Individual
Prefix:DR
First Name:NAGASHREE
Middle Name:BALUR
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9204 MENAUL BLVD NE STE 3
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-2201
Mailing Address - Country:US
Mailing Address - Phone:505-299-6112
Mailing Address - Fax:505-299-7718
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-1529
Practice Address - Country:US
Practice Address - Phone:505-766-5197
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA548391223G0001X
NMDD32751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM52932532Medicaid