Active NPI
Gangadhar Immanni, DDS
- General Practice Dentistry
- Portales, NM
National Provider Identifier
1912285032
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- DD3547
- Practice address
- 1515 West Fir
Portales, NM 88130 - Phone
- (575) 356-6695
- Fax
- (575) 356-5948
- NPI assigned
- Jul 22, 2011
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | DD3547 | NM | Primary |
Addresses
Primary practice location
1515 West Fir
Portales, NM 88130
Mailing address
1515 West Fir
PO Box 843
Portales, NM 88130
Phone (575) 356-6695
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| DD3547 | NM | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1311292800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1352764800000",
"number": "1912285032",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1515 WEST FIR",
"address_2": "PO BOX 843",
"city": "PORTALES",
"state": "NM",
"postal_code": "88130",
"telephone_number": "575-356-6695",
"fax_number": "575-356-5948"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1515 WEST FIR",
"city": "PORTALES",
"state": "NM",
"postal_code": "88130",
"telephone_number": "575-356-6695",
"fax_number": "575-356-5948"
}
],
"practiceLocations": [],
"basic": {
"last_name": "IMMANNI",
"first_name": "GANGADHAR",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2011-07-22",
"last_updated": "2012-11-13",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "NM",
"license": "DD3547",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Portales, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 13, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.