Basic Information
| Provider Information | |||||||||
| NPI: | 1295013514 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SUNDARAGOPAL | ||||||||
| FirstName: | NISHA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | SUNDARAGOPAL | ||||||||
| OtherFirstName: | NISHA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 11767 KATY FWY | ||||||||
| Address2: | STE 505 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770791768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816799340 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5300 SAN DARIO AVE | ||||||||
| Address2: | #C2 | ||||||||
| City: | LAREDO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780413000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9567236568 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2011 | ||||||||
| LastUpdateDate: | 02/26/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | 27303 | TX | Y | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.