Individual
SANDEEP THOTA
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
1407 N VETERANS PKWY, BLOOMINGTON, IL 61704-6630
(314) 651-6550
Mailing address
1407 N VETERANS PKWY, BLOOMINGTON, IL 61704-6630
(314) 651-6550
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12012339A
IN
Other
Enumeration date
06/29/2015
Last updated
06/29/2015
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