Provider Demographics
NPI:1043563182
Name:AMBATIPUDI, NAGAMANI (DMD)
Entity Type:Individual
Prefix:
First Name:NAGAMANI
Middle Name:
Last Name:AMBATIPUDI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 MIDDLE TURNPIKE W
Mailing Address - Street 2:SUITE 309
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040
Mailing Address - Country:US
Mailing Address - Phone:860-645-0111
Mailing Address - Fax:860-432-4613
Practice Address - Street 1:483 MIDDLE TURNPIKE W
Practice Address - Street 2:SUITE 309
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040
Practice Address - Country:US
Practice Address - Phone:860-645-0111
Practice Address - Fax:860-432-4613
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT010499122300000X
CT104991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist