Provider Demographics
NPI:1750936985
Name:NATARAJAN, MANJU
Entity type:Individual
Prefix:
First Name:MANJU
Middle Name:
Last Name:NATARAJAN
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 1:290 QUARRY ST APT 712
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4154
Mailing Address - Country:US
Mailing Address - Phone:859-806-7149
Mailing Address - Fax:
Practice Address - Street 1:635, ALBANY STREET
Practice Address - Street 2:ROOM NO 306
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-358-4103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADL14110122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist