Provider Demographics
NPI:1457419293
Name:MALLIPEDDI, VANI (DMD)
Entity Type:Individual
Prefix:
First Name:VANI
Middle Name:
Last Name:MALLIPEDDI
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 1:28 W COLE RD STE 104
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9428
Mailing Address - Country:US
Mailing Address - Phone:207-282-3928
Mailing Address - Fax:207-284-1231
Practice Address - Street 1:28 W COLE RD STE 104
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9428
Practice Address - Country:US
Practice Address - Phone:207-282-3928
Practice Address - Fax:207-284-1231
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432245199Medicaid