Provider Demographics
NPI:1114193901
Name:BHOOMPALLI, MADHAVI (DDS)
Entity Type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:
Last Name:BHOOMPALLI
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 1:6115 ABBOTTS BRIDGE RD
Mailing Address - Street 2:APT 1901
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-5751
Mailing Address - Country:US
Mailing Address - Phone:678-691-7219
Mailing Address - Fax:
Practice Address - Street 1:6115 ABBOTTS BRIDGE RD
Practice Address - Street 2:APT 1901
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-5751
Practice Address - Country:US
Practice Address - Phone:678-691-7219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013603122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist