Provider Demographics
NPI:1275652414
Name:MANDAVA, SREEDEVI (DDS)
Entity Type:Individual
Prefix:DR
First Name:SREEDEVI
Middle Name:
Last Name:MANDAVA
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 1:3912 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-6508
Mailing Address - Country:US
Mailing Address - Phone:518-883-4505
Mailing Address - Fax:518-883-3228
Practice Address - Street 1:3912 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-6508
Practice Address - Country:US
Practice Address - Phone:518-883-4505
Practice Address - Fax:518-883-3228
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01917046Medicare ID - Type Unspecified