Provider Demographics
NPI:1952531915
Name:MANCHUKONDA, RAJEEV (DMD)
Entity type:Individual
Prefix:DR
First Name:RAJEEV
Middle Name:
Last Name:MANCHUKONDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6680 NANTUCKET LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44130-8483
Mailing Address - Country:US
Mailing Address - Phone:270-366-3465
Mailing Address - Fax:
Practice Address - Street 1:11501 LORAIN AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5402
Practice Address - Country:US
Practice Address - Phone:216-476-9930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-23
Last Update Date:2016-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-0242871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice