Provider Demographics
NPI:1760058309
Name:TANNA MADHAVANI, MANALI (DMD)
Entity Type:Individual
Prefix:
First Name:MANALI
Middle Name:
Last Name:TANNA MADHAVANI
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 1:425 E LAMAR BLVD APT 455
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76011-1200
Mailing Address - Country:US
Mailing Address - Phone:872-215-2605
Mailing Address - Fax:
Practice Address - Street 1:425 E LAMAR BLVD APT 455
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-1200
Practice Address - Country:US
Practice Address - Phone:872-215-2605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX371991223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics