Provider Demographics
NPI:1861891079
Name:RAKESHMANTENA DDS CORP
Entity type:Organization
Organization Name:RAKESHMANTENA DDS CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAKESH
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTENA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-718-0005
Mailing Address - Street 1:4355 TOWN CENTER BLVD
Mailing Address - Street 2:SUITE 211
Mailing Address - City:EL DORADO HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:95762-7115
Mailing Address - Country:US
Mailing Address - Phone:916-939-6777
Mailing Address - Fax:916-939-5077
Practice Address - Street 1:4355 TOWN CENTER BLVD
Practice Address - Street 2:SUITE 211
Practice Address - City:EL DORADO HILLS
Practice Address - State:CA
Practice Address - Zip Code:95762-7115
Practice Address - Country:US
Practice Address - Phone:916-939-6777
Practice Address - Fax:916-939-5077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58253305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service