Provider Demographics
NPI:1831192251
Name:MANNEM, SASI KALA (DDS)
Entity type:Individual
Prefix:DR
First Name:SASI
Middle Name:KALA
Last Name:MANNEM
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 1:2103 MCHENRY AVENUE
Mailing Address - Street 2:SUITE C
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-435-9550
Mailing Address - Fax:
Practice Address - Street 1:2103 MCHENRY AVENUE
Practice Address - Street 2:SUITE C
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-435-9550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX195781223G0001X
CA1013871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice