Provider Demographics
NPI:1619155587
Name:MUKUNDAN, MADHAV (DDS)
Entity Type:Individual
Prefix:DR
First Name:MADHAV
Middle Name:
Last Name:MUKUNDAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GLENWOOD CIR APT 214
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-4710
Mailing Address - Country:US
Mailing Address - Phone:917-385-0549
Mailing Address - Fax:
Practice Address - Street 1:1053 S GREEN VALLEY RD
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-4164
Practice Address - Country:US
Practice Address - Phone:831-515-3006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-03
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA592391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice