1447921200 NPI number — DR. VIJAYA LAKSHMI PAVAN MOLLI DDS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447921200 NPI number — DR. VIJAYA LAKSHMI PAVAN MOLLI DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOLLI
Provider First Name:
VIJAYA LAKSHMI PAVAN
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KONDRU
Provider Other First Name:
VIJAYA LAKSHMI PAVAN
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS PERIODONTICS
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1447921200
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2701 W ROYAL LANE, APT 805
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-764-1496
Provider Business Mailing Address Fax Number:
817-997-4342

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4021 REGGIS CT STE 313
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76155-3958
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-764-1496
Provider Business Practice Location Address Fax Number:
817-997-4342
Provider Enumeration Date:
09/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  37900 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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