Provider Demographics
NPI:1336309152
Name:MUKKAMALA, RAJSEKHAR (DDS)
Entity Type:Individual
Prefix:
First Name:RAJSEKHAR
Middle Name:
Last Name:MUKKAMALA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5760 FOSSANO DRIVE
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34238
Mailing Address - Country:US
Mailing Address - Phone:941-927-9070
Mailing Address - Fax:
Practice Address - Street 1:3030 US HIGHWAY 301 N
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2010
Practice Address - Country:US
Practice Address - Phone:941-722-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-16
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist