Provider Demographics
NPI:1154310985
Name:MOHAN, MANEESH (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANEESH
Middle Name:
Last Name:MOHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 STATE ST
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:IN
Mailing Address - Zip Code:47150-4962
Mailing Address - Country:US
Mailing Address - Phone:812-944-7200
Mailing Address - Fax:812-945-3260
Practice Address - Street 1:5100 OUTER LOOP
Practice Address - Street 2:SUITE B
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3201
Practice Address - Country:US
Practice Address - Phone:502-966-8660
Practice Address - Fax:502-969-8444
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2014-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81911223S0112X
IN12011030A1223S0112X
KY8181204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200872180Medicaid
KY9179239OtherDORAL
KY6411381400Medicaid
KY204E0000XMedicaid
KY50007575OtherPASSPORT