Individual
DR. GANGADHAR IMMANNI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1515 WEST FIR, PORTALES, NM 88130
(575) 356-6695
(575) 356-5948
Mailing address
1515 WEST FIR, PO BOX 843, PORTALES, NM 88130
(575) 356-6695
(575) 356-5948
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
DD3547
NM
Other
Enumeration date
07/22/2011
Last updated
11/13/2012
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