Provider Demographics
NPI:1396006458
Name:MUNDRA, DEEPTHI (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEEPTHI
Middle Name:
Last Name:MUNDRA
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 1:102 CHILTON PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7810
Mailing Address - Country:US
Mailing Address - Phone:773-844-3439
Mailing Address - Fax:
Practice Address - Street 1:SMILE CARE, PLLC
Practice Address - Street 2:1237 HIGHWAY 35 S
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-8830
Practice Address - Country:US
Practice Address - Phone:601-469-8266
Practice Address - Fax:601-469-8294
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6907-151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice