Provider Demographics
NPI:1154468098
Name:NEERUMALLA, MADHAVI -------------------- (DDS)
Entity Type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:--------------------
Last Name:NEERUMALLA
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 1:513 PYRAMID CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534
Mailing Address - Country:US
Mailing Address - Phone:707-864-8871
Mailing Address - Fax:
Practice Address - Street 1:2440 N.TEXAS ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533
Practice Address - Country:US
Practice Address - Phone:707-422-4696
Practice Address - Fax:707-422-0396
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50497122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist