Provider Demographics
NPI:1366868697
Name:DR MANDAVA DDS FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:DR MANDAVA DDS FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RATNAKAR
Authorized Official - Middle Name:R
Authorized Official - Last Name:MANDAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:203-758-2116
Mailing Address - Street 1:415 MIDDLEBURY RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-2537
Mailing Address - Country:US
Mailing Address - Phone:203-758-2116
Mailing Address - Fax:203-758-9522
Practice Address - Street 1:415 MIDDLEBURY RD
Practice Address - Street 2:
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-2537
Practice Address - Country:US
Practice Address - Phone:203-758-2116
Practice Address - Fax:203-758-9522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty