Provider Demographics
NPI:1174678718
Name:MADANI, MITRA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MITRA
Middle Name:
Last Name:MADANI
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 1:517 BENFIELD RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2527
Mailing Address - Country:US
Mailing Address - Phone:410-647-7050
Mailing Address - Fax:410-647-7051
Practice Address - Street 1:517 BENFIELD RD
Practice Address - Street 2:SUITE 204
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2527
Practice Address - Country:US
Practice Address - Phone:410-647-7050
Practice Address - Fax:410-647-7051
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2014-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD135641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice