Provider Demographics
NPI:1164094330
Name:MUKKARA HAGERSTOWN LLC
Entity Type:Organization
Organization Name:MUKKARA HAGERSTOWN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MAMATA
Authorized Official - Middle Name:
Authorized Official - Last Name:MUKKARA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, CAGS, DSCD
Authorized Official - Phone:617-480-2348
Mailing Address - Street 1:7 KILGLASS CT APT 102
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-7782
Mailing Address - Country:US
Mailing Address - Phone:617-480-2348
Mailing Address - Fax:
Practice Address - Street 1:322 E ANTIETAM ST STE 103
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-5736
Practice Address - Country:US
Practice Address - Phone:301-733-1552
Practice Address - Fax:301-733-1553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty