Provider Demographics
NPI:1811965114
Name:MUTYALA, PADMAJA K (DDS)
Entity type:Individual
Prefix:DR
First Name:PADMAJA
Middle Name:K
Last Name:MUTYALA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 CRABBET PARK DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-9227
Mailing Address - Country:US
Mailing Address - Phone:661-663-9221
Mailing Address - Fax:
Practice Address - Street 1:13029 STOCKDALE HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93314-9589
Practice Address - Country:US
Practice Address - Phone:661-829-7905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-10
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist