Provider Demographics
NPI:1558630251
Name:MAVALLI, MAHENDRA D (DDS, MS, PHD)
Entity Type:Individual
Prefix:DR
First Name:MAHENDRA
Middle Name:D
Last Name:MAVALLI
Suffix:
Gender:M
Credentials:DDS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 RIDGE POINT PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-8801
Mailing Address - Country:US
Mailing Address - Phone:817-697-5166
Mailing Address - Fax:
Practice Address - Street 1:151 RIDGE POINT PKWY STE 100
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-8801
Practice Address - Country:US
Practice Address - Phone:817-697-5166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-26
Last Update Date:2022-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX273921223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry