Provider Demographics
NPI:1528014602
Name:MADDALI, RAVI C (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:C
Last Name:MADDALI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 W 173RD ST
Mailing Address - Street 2:SUITE # 1 A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10032-1425
Mailing Address - Country:US
Mailing Address - Phone:212-928-4480
Mailing Address - Fax:212-928-8389
Practice Address - Street 1:639 W 173RD ST
Practice Address - Street 2:SUITE # 1 A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-1425
Practice Address - Country:US
Practice Address - Phone:212-928-4480
Practice Address - Fax:212-928-8389
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0459221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704829Medicaid