Provider Demographics
NPI:1750317509
Name:MANTHA, MURTHY N (BDS)
Entity Type:Individual
Prefix:DR
First Name:MURTHY
Middle Name:N
Last Name:MANTHA
Suffix:
Gender:M
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11600 N LANTERN LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1574
Mailing Address - Country:US
Mailing Address - Phone:262-238-1010
Mailing Address - Fax:
Practice Address - Street 1:1135 S CESAR CHAVEZ DRIVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204
Practice Address - Country:US
Practice Address - Phone:414-645-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2795-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice