Provider Demographics
NPI:1265696173
Name:JONATHAN L MADDATU DDS INC
Entity type:Organization
Organization Name:JONATHAN L MADDATU DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
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 1:6736 N. SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411
Mailing Address - Country:US
Mailing Address - Phone:818-786-8803
Mailing Address - Fax:818-786-8570
Practice Address - Street 1:6736 N. SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-3306
Practice Address - Country:US
Practice Address - Phone:818-786-8803
Practice Address - Fax:818-786-8570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty