Provider Demographics
NPI:1811511470
Name:MANDAVILLI, GEETA GYANESHWARI
Entity type:Individual
Prefix:
First Name:GEETA
Middle Name:GYANESHWARI
Last Name:MANDAVILLI
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 1:301 COUNTY ROAD 207 APT 1110
Mailing Address - Street 2:
Mailing Address - City:ALVARADO
Mailing Address - State:TX
Mailing Address - Zip Code:76009-1450
Mailing Address - Country:US
Mailing Address - Phone:334-488-9669
Mailing Address - Fax:
Practice Address - Street 1:3080 N EASTMAN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-5174
Practice Address - Country:US
Practice Address - Phone:903-686-0086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-29
Last Update Date:2021-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX368401223G0001X
LA7054-PR1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice