Provider Demographics
NPI:1750611125
Name:MUDIYANSELAGE, RATHNASIRI K (DDS)
Entity type:Individual
Prefix:
First Name:RATHNASIRI
Middle Name:K
Last Name:MUDIYANSELAGE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3736 MYKONOS LN UNIT 128
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-5545
Mailing Address - Country:US
Mailing Address - Phone:626-698-1152
Mailing Address - Fax:
Practice Address - Street 1:3736 MYKONOS LN UNIT 128
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-5545
Practice Address - Country:US
Practice Address - Phone:626-698-1152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA589121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice