Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 24561 | TX |
NPI | 1023243375 |
---|---|
Provider Name | Archana Gutta |
First Address | Midland, TX 79703-5131 |
Second Address | Midland, TX 79703-5131 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 15/05/2009 |
Last Update Date | 03/10/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
202112310 | (05) | TX |