Provider Demographics
NPI:1790291151
Name:SERI, MADHAVI SURESH
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:SURESH
Last Name:SERI
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 1:1940 N TRACY BLVD
Mailing Address - Street 2:
Mailing Address - City:TRACY
Mailing Address - State:CA
Mailing Address - Zip Code:95376-2423
Mailing Address - Country:US
Mailing Address - Phone:209-666-2162
Mailing Address - Fax:
Practice Address - Street 1:1940 N TRACY BLVD
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-2423
Practice Address - Country:US
Practice Address - Phone:209-666-2162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist