Provider Demographics
NPI:1518284660
Name:MANDALIA, AMY VINODKUMAR
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:VINODKUMAR
Last Name:MANDALIA
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 1:900 PEACHTREE ST NE
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-5900
Mailing Address - Country:US
Mailing Address - Phone:678-321-1888
Mailing Address - Fax:678-321-1777
Practice Address - Street 1:900 PEACHTREE ST NE
Practice Address - Street 2:SUITE 100A
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-5900
Practice Address - Country:US
Practice Address - Phone:678-321-1888
Practice Address - Fax:678-321-1777
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-29
Last Update Date:2013-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN014024122300000X
PADS037986122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist