Provider Demographics
NPI:1215209366
Name:MANDADI, SIRISHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SIRISHA
Middle Name:
Last Name:MANDADI
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 1:4627 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-1155
Mailing Address - Country:US
Mailing Address - Phone:203-921-5269
Mailing Address - Fax:
Practice Address - Street 1:2241 THEODORE ST
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60403-1881
Practice Address - Country:US
Practice Address - Phone:815-741-1700
Practice Address - Fax:815-741-8511
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10019771223P0700X
IL0210027941223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty