Provider Demographics
NPI:1780878496
Name:PONNAGANTI, MAMATA (DMD)
Entity type:Individual
Prefix:
First Name:MAMATA
Middle Name:
Last Name:PONNAGANTI
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 1:706 S FORT HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756-5304
Mailing Address - Country:US
Mailing Address - Phone:727-443-6305
Mailing Address - Fax:727-443-6856
Practice Address - Street 1:706 S FORT HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-5304
Practice Address - Country:US
Practice Address - Phone:727-443-6305
Practice Address - Fax:727-443-6856
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN152261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice