Provider Demographics
NPI:1568500080
Name:MADDALI, ANITA R (DMD)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:R
Last Name:MADDALI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 BURNSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3405
Mailing Address - Country:US
Mailing Address - Phone:860-899-1361
Mailing Address - Fax:860-899-1361
Practice Address - Street 1:47 BURNSIDE AVE
Practice Address - Street 2:
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-3405
Practice Address - Country:US
Practice Address - Phone:860-899-1360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA21759MA1223G0001X
CT94811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice