Provider Demographics
NPI:1528223054
Name:MANDA, ANIL KUMAR REDDY (DMD)
Entity Type:Individual
Prefix:
First Name:ANIL KUMAR REDDY
Middle Name:
Last Name:MANDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:866-803-4943
Practice Address - Street 1:5020 WEST LLOYD EXPWY
Practice Address - Street 2:STE 200
Practice Address - City:EVANSVILLE,
Practice Address - State:IN
Practice Address - Zip Code:47712
Practice Address - Country:US
Practice Address - Phone:812-463-8000
Practice Address - Fax:812-463-8104
Is Sole Proprietor?:No
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011176A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist