Provider Demographics
NPI:1174752349
Name:GANTA, ANURADHA (DR)
Entity type:Individual
Prefix:
First Name:ANURADHA
Middle Name:
Last Name:GANTA
Suffix:
Gender:F
Credentials:DR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TUNISON LN
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-2440
Mailing Address - Country:US
Mailing Address - Phone:763-222-8485
Mailing Address - Fax:
Practice Address - Street 1:327 TOWNSHIP LINE RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-2222
Practice Address - Country:US
Practice Address - Phone:215-663-1223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-09
Last Update Date:2009-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0375621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice