Provider Demographics
NPI:1417023052
Name:PASALA, MAMATHA (DDS)
Entity Type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:PASALA
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 1:6000 SHEPHERD MOUNTAIN CV
Mailing Address - Street 2:#418
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78730-4923
Mailing Address - Country:US
Mailing Address - Phone:650-796-3393
Mailing Address - Fax:
Practice Address - Street 1:6000 SHEPHERD MOUNTAIN CV
Practice Address - Street 2:#418
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78730-4923
Practice Address - Country:US
Practice Address - Phone:650-796-3393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2008-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX229251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice