Provider Demographics
NPI:1447538400
Name:KONDRAGUNTA, SUMAN KISHORE (DDS)
Entity type:Individual
Prefix:DR
First Name:SUMAN
Middle Name:KISHORE
Last Name:KONDRAGUNTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 FRANKLIN AVE
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-2529
Mailing Address - Country:US
Mailing Address - Phone:346-201-5656
Mailing Address - Fax:
Practice Address - Street 1:2400 E OLTORF ST # 100B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4563
Practice Address - Country:US
Practice Address - Phone:512-822-7275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-25
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35481223G0001X
TXTX28527122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice