Provider Demographics
NPI:1164842407
Name:MABANDLA, BUHLEBENKOSI PRISCA
Entity Type:Individual
Prefix:
First Name:BUHLEBENKOSI
Middle Name:PRISCA
Last Name:MABANDLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 290
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6402
Mailing Address - Country:US
Mailing Address - Phone:202-520-7469
Mailing Address - Fax:
Practice Address - Street 1:1090 NORTHCHASE PKWY SE STE 290
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6402
Practice Address - Country:US
Practice Address - Phone:202-520-7469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31473122300000X
390200000X
MD165931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program