Provider Demographics
NPI:1194205427
Name:QANDLA, MAIRNA
Entity Type:Individual
Prefix:DR
First Name:MAIRNA
Middle Name:
Last Name:QANDLA
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 1:10500 AVERY CLUB DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78717-3937
Mailing Address - Country:US
Mailing Address - Phone:512-705-2315
Mailing Address - Fax:
Practice Address - Street 1:10500 AVERY CLUB DR UNIT 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78717-3937
Practice Address - Country:US
Practice Address - Phone:512-705-2315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34374122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist