Provider Demographics
NPI:1164054235
Name:MINISANDRAM, AMRITHA RAGHUNATH (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMRITHA
Middle Name:RAGHUNATH
Last Name:MINISANDRAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7058 HEARTLAND WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95135-2234
Mailing Address - Country:US
Mailing Address - Phone:408-431-2471
Mailing Address - Fax:
Practice Address - Street 1:7058 HEARTLAND WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95135-2234
Practice Address - Country:US
Practice Address - Phone:408-431-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-06
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA104478122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist