Provider Demographics
NPI:1295405025
Name:MANDAPATI, PRASIDA (DDS)
Entity Type:Individual
Prefix:
First Name:PRASIDA
Middle Name:
Last Name:MANDAPATI
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 1:25615 ELLIS RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-6046
Mailing Address - Country:US
Mailing Address - Phone:281-450-6353
Mailing Address - Fax:
Practice Address - Street 1:16810 MERIDIAN AVE E STE J107
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98375
Practice Address - Country:US
Practice Address - Phone:253-848-7777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37815122300000X
WADE61387262122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX37815Medicaid