Provider Demographics
NPI:1912485921
Name:MONGA, PRIYANKA RAJU
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:RAJU
Last Name:MONGA
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 1:2141 NORTH FAIRFIELD ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431
Mailing Address - Country:US
Mailing Address - Phone:937-427-3131
Mailing Address - Fax:
Practice Address - Street 1:2141 NORTH FAIRFIELD ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-427-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2021-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH30.026607122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program