Provider Demographics
NPI:1083780159
Name:KORI, MAMTA M (DDS)
Entity Type:Individual
Prefix:
First Name:MAMTA
Middle Name:M
Last Name:KORI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 ATRIUM BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:45005-5186
Mailing Address - Country:US
Mailing Address - Phone:855-912-7677
Mailing Address - Fax:513-424-2147
Practice Address - Street 1:3420 ATRIUM BLVD STE 100
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:45005-5186
Practice Address - Country:US
Practice Address - Phone:855-912-7677
Practice Address - Fax:513-424-2147
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH215411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2371866Medicaid