Provider Demographics
NPI:1093176380
Name:USHA MANTENA DENTAL CORPORATION
Entity Type:Organization
Organization Name:USHA MANTENA DENTAL CORPORATION
Other - Org Name:VACAVILLE DENTISTRY AND ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:USHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANTENA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-215-5259
Mailing Address - Street 1:17000 RED HILL AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5626
Mailing Address - Country:US
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:671 ELMIRA RD
Practice Address - Street 2:SUITE 130
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-4655
Practice Address - Country:US
Practice Address - Phone:707-215-5259
Practice Address - Fax:707-416-2828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty