Provider Demographics
NPI:1104304542
Name:MAMMEN, REJI
Entity type:Individual
Prefix:
First Name:REJI
Middle Name:
Last Name:MAMMEN
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 1:2120 EL PASEO ST APT 2607
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3232
Mailing Address - Country:US
Mailing Address - Phone:832-270-6851
Mailing Address - Fax:
Practice Address - Street 1:2120 EL PASEO ST., APT 2607
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054
Practice Address - Country:US
Practice Address - Phone:832-270-6851
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-28
Last Update Date:2018-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX34406122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist