Provider Demographics
NPI:1710208004
Name:MANDALA, SRINIVAS REDDY (DMD)
Entity type:Individual
Prefix:DR
First Name:SRINIVAS
Middle Name:REDDY
Last Name:MANDALA
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 1:220 ANNABELLE BRANCH LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27523-5826
Mailing Address - Country:US
Mailing Address - Phone:757-289-7354
Mailing Address - Fax:
Practice Address - Street 1:8-5476 A SOUTER, BUTNER RD
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28307
Practice Address - Country:US
Practice Address - Phone:910-728-4348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10274122300000X
MADN18564191223G0001X
NC105721223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist