Provider Demographics
NPI:1255498861
Name:MUKKARA, MAMATA (DMD, DSCD, CAGS)
Entity Type:Individual
Prefix:DR
First Name:MAMATA
Middle Name:
Last Name:MUKKARA
Suffix:
Gender:F
Credentials:DMD, DSCD, CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2221 E BIJOU ST STE 100
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-8009
Mailing Address - Country:US
Mailing Address - Phone:719-576-1850
Mailing Address - Fax:719-955-3470
Practice Address - Street 1:5632 THE ALAMEDA
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2737
Practice Address - Country:US
Practice Address - Phone:617-480-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD158761223X0400X, 1223X0400X
OK6670122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC091615433Medicaid
MD109820900Medicaid