Provider Demographics
NPI:1790118222
Name:DR. J L MADDATU DENTAL CORP.
Entity Type:Organization
Organization Name:DR. J L MADDATU DENTAL CORP.
Other - Org Name:JONATHAN L. MADDATU DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LORENZO
Authorized Official - Last Name:MADDATU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-786-8803
Mailing Address - Street 1:44841 10TH ST W
Mailing Address - Street 2:NONE
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2311
Mailing Address - Country:US
Mailing Address - Phone:661-948-1655
Mailing Address - Fax:661-940-9636
Practice Address - Street 1:44841 10TH ST W
Practice Address - Street 2:NONE
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2311
Practice Address - Country:US
Practice Address - Phone:661-948-1655
Practice Address - Fax:661-940-9636
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JONATHAN L. MADDATU DDS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty