1740482116 NPI number — MRUDULA PINGILI DDS ,LLC

Table of content: MS. SHELLEY ANN HOUSTON LMFT (NPI 1285941880)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740482116 NPI number — MRUDULA PINGILI DDS ,LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MRUDULA PINGILI DDS ,LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DENTAL COSMETIC CONCEPTS
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740482116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
390 AMWELL RD
Provider Second Line Business Mailing Address:
SUITE 408 , BUILDING 4
Provider Business Mailing Address City Name:
HILLSBOROUGH
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08844-1225
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-874-5006
Provider Business Mailing Address Fax Number:
908-874-8272

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
390 AMWELL RD
Provider Second Line Business Practice Location Address:
SUITE 408 , BUILDING 4
Provider Business Practice Location Address City Name:
HILLSBOROUGH
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08844-1225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-874-5006
Provider Business Practice Location Address Fax Number:
908-874-8272
Provider Enumeration Date:
06/05/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PINGILI
Authorized Official First Name:
MRUDULA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
908-874-5006

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22DI02220500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)