Provider Demographics
NPI:1831704873
Name:MUNDLURU, TARUN
Entity type:Individual
Prefix:
First Name:TARUN
Middle Name:
Last Name:MUNDLURU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PECOS DENTAL, 801 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:PECOS
Mailing Address - State:TX
Mailing Address - Zip Code:79772
Mailing Address - Country:US
Mailing Address - Phone:432-445-3333
Mailing Address - Fax:
Practice Address - Street 1:PECOS DENTAL, 801 W 3RD ST
Practice Address - Street 2:
Practice Address - City:PECOS
Practice Address - State:TX
Practice Address - Zip Code:79772
Practice Address - Country:US
Practice Address - Phone:432-445-3333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-15
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX367181223X2210X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X2210XDental ProvidersDentistOrofacial Pain