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Organization
REVITAL DENTAL PLLC
Active
Organization
REVITAL DENTAL PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
SUMAN KISHORE KONDRAGUNTA DDS (MEMBER)
(347) 631-0848
Entity
Organization
Contact information
Practice address
4311 S 31ST ST STE 145, TEMPLE, TX 76502-3346
(347) 631-0848
Mailing address
4311 S 31ST ST STE 145, TEMPLE, TX 76502-3346
(347) 631-0848
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
—
261QD0000X
Dental Clinic/Center
—
—
Other
Enumeration date
04/01/2022
Last updated
09/14/2023
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