Provider Demographics
NPI:1679762694
Name:BHATTA, GAUTAM (DDS)
Entity type:Individual
Prefix:
First Name:GAUTAM
Middle Name:
Last Name:BHATTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 W ALABAMA ST
Mailing Address - Street 2:SUITE 150
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77027-5924
Mailing Address - Country:US
Mailing Address - Phone:713-888-0664
Mailing Address - Fax:713-888-0667
Practice Address - Street 1:3637 W ALABAMA ST
Practice Address - Street 2:SUITE 150
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77027-5924
Practice Address - Country:US
Practice Address - Phone:713-888-0664
Practice Address - Fax:713-888-0667
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX190711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice