Provider Demographics
NPI:1558763607
Name:MUMMANENI, PRANEETHA
Entity Type:Individual
Prefix:
First Name:PRANEETHA
Middle Name:
Last Name:MUMMANENI
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 1:1138 HIDDEN RDG APT 1216
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038-8341
Mailing Address - Country:US
Mailing Address - Phone:309-643-5749
Mailing Address - Fax:
Practice Address - Street 1:1138 HIDDEN RDG APT 1216
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75038-8341
Practice Address - Country:US
Practice Address - Phone:309-643-5749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30502122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist