Provider Demographics
NPI:1346061884
Name:NAMBALA, DEEPTHI (BDS)
Entity type:Individual
Prefix:DR
First Name:DEEPTHI
Middle Name:
Last Name:NAMBALA
Suffix:
Gender:F
Credentials:BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19839 IRIS WAY
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-3547
Mailing Address - Country:US
Mailing Address - Phone:425-351-0826
Mailing Address - Fax:
Practice Address - Street 1:SPECIAL HEALTHCARE NEEDS DENTAL CLINIC
Practice Address - Street 2:MALCOLM HEALTH SCIENCES MOOS TOWER, 515 DELAWARE ST. SE
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-4777
Practice Address - Fax:612-625-0613
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-17
Last Update Date:2024-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR890122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist