Provider Demographics
NPI:1447921200
Name:MOLLI, VIJAYA LAKSHMI PAVAN (DDS)
Entity type:Individual
Prefix:DR
First Name:VIJAYA LAKSHMI PAVAN
Middle Name:
Last Name:MOLLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VIJAYA LAKSHMI PAVAN
Other - Middle Name:
Other - Last Name:KONDRU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS PERIODONTICS
Mailing Address - Street 1:2701 W ROYAL LANE, APT 805
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75063
Mailing Address - Country:US
Mailing Address - Phone:817-764-1496
Mailing Address - Fax:817-997-4342
Practice Address - Street 1:4021 REGGIS CT STE 313
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-3958
Practice Address - Country:US
Practice Address - Phone:817-764-1496
Practice Address - Fax:817-997-4342
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX379001223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty