Provider Demographics
NPI:1932865714
Name:MUTNURI, VENKATA MOHAN K (DDS)
Entity Type:Individual
Prefix:
First Name:VENKATA MOHAN
Middle Name:K
Last Name:MUTNURI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 S COIT RD APT 905
Mailing Address - Street 2:
Mailing Address - City:PROSPER
Mailing Address - State:TX
Mailing Address - Zip Code:75078-3011
Mailing Address - Country:US
Mailing Address - Phone:201-970-0273
Mailing Address - Fax:
Practice Address - Street 1:1141 KELLER PKWY STE B
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-1628
Practice Address - Country:US
Practice Address - Phone:817-753-0226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX375861223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics