Provider Demographics
NPI:1659722510
Name:MANDAL, PRIYANKA (DDS)
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:MANDAL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 AVENUE C NW
Mailing Address - Street 2:
Mailing Address - City:CHILDRESS
Mailing Address - State:TX
Mailing Address - Zip Code:79201-4317
Mailing Address - Country:US
Mailing Address - Phone:305-205-7648
Mailing Address - Fax:
Practice Address - Street 1:4109 HILLCREST PLZ
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:TX
Practice Address - Zip Code:76384-3267
Practice Address - Country:US
Practice Address - Phone:940-552-2269
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist