Provider Demographics
NPI:1760632475
Name:MUTHUKURU, MANOJ (BDS,PHD)
Entity Type:Individual
Prefix:DR
First Name:MANOJ
Middle Name:
Last Name:MUTHUKURU
Suffix:
Gender:M
Credentials:BDS,PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1959 NE PACIFIC ST
Mailing Address - Street 2:BOX 357131
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:206-685-8258
Mailing Address - Fax:206-616-8545
Practice Address - Street 1:1959 NE PACIFIC ST
Practice Address - Street 2:BOX 357131
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-685-8258
Practice Address - Fax:206-616-8545
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADF600345131223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics