Provider Demographics
NPI:1598799199
Name:WELIKALA, MANOHARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:MANOHARA
Middle Name:
Last Name:WELIKALA
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 1:55 W LOS ANGELES AVE
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-1820
Mailing Address - Country:US
Mailing Address - Phone:805-523-3216
Mailing Address - Fax:805-523-9630
Practice Address - Street 1:55 W LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:MOORPARK
Practice Address - State:CA
Practice Address - Zip Code:93021-1820
Practice Address - Country:US
Practice Address - Phone:805-523-3216
Practice Address - Fax:805-523-9630
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49243122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92552-01OtherDENTI-CAL
CAB49243OtherCALIFORNIA HELTHY FAMILY