Provider Demographics
NPI:1275103293
Name:MANOHARAN, REKHA (DMD)
Entity Type:Individual
Prefix:
First Name:REKHA
Middle Name:
Last Name:MANOHARAN
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 1:2706 SCATTERBY CV
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-7990
Mailing Address - Country:US
Mailing Address - Phone:973-580-5675
Mailing Address - Fax:
Practice Address - Street 1:1530 TEXAS AVE S STE 300
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-3390
Practice Address - Country:US
Practice Address - Phone:973-580-5675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-30
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37365122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Yes122300000XDental ProvidersDentist