Provider Demographics
NPI:1376806893
Name:MUDDANA, PRAVEENA
Entity Type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:MUDDANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-464-6000
Mailing Address - Fax:
Practice Address - Street 1:8241 S HOWELL AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:OAK CREEK
Practice Address - State:WI
Practice Address - Zip Code:53154-8346
Practice Address - Country:US
Practice Address - Phone:414-762-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-19
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6931-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice