Provider Demographics
NPI:1508054982
Name:MANTHINA, RADHIKA
Entity Type:Individual
Prefix:DR
First Name:RADHIKA
Middle Name:
Last Name:MANTHINA
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 1:4522 HAMILTON AVE
Mailing Address - Street 2:#3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95130-1424
Mailing Address - Country:US
Mailing Address - Phone:408-396-7377
Mailing Address - Fax:
Practice Address - Street 1:4522 HAMILTON AVE
Practice Address - Street 2:#3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95130-1424
Practice Address - Country:US
Practice Address - Phone:408-396-7377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-10
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55821122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD55821Medicaid