Provider Demographics
NPI:1225295009
Name:CHENEPALLI, MAMATHA (DMD)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:CHENEPALLI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6768 193RD PL NE
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-0567
Mailing Address - Country:US
Mailing Address - Phone:425-558-1618
Mailing Address - Fax:
Practice Address - Street 1:22625 PACIFIC HWY S
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-5110
Practice Address - Country:US
Practice Address - Phone:206-878-5665
Practice Address - Fax:206-870-1504
Is Sole Proprietor?:No
Enumeration Date:2008-05-20
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00009662122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist