Provider Demographics
NPI:1780031203
Name:MANDARA, ASHIKA
Entity Type:Individual
Prefix:
First Name:ASHIKA
Middle Name:
Last Name:MANDARA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 N CLARK ST STE 600
Mailing Address - Street 2:C/O KOS SERVICES
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4782
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1851 S COLUMBUS BLVD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2800
Practice Address - Country:US
Practice Address - Phone:215-755-2559
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-16
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0409571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice