Provider Demographics
NPI:1144320367
Name:MYNENI, SRIRAM V (DDS)
Entity type:Individual
Prefix:DR
First Name:SRIRAM
Middle Name:V
Last Name:MYNENI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:935 MAIN ST STE B2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-6050
Mailing Address - Country:US
Mailing Address - Phone:860-643-0011
Mailing Address - Fax:860-646-8548
Practice Address - Street 1:935 MAIN ST
Practice Address - Street 2:SUITE # B2
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-6059
Practice Address - Country:US
Practice Address - Phone:860-643-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0105901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice