Provider Demographics
NPI:1902970239
Name:RAMANA, MANJULA (DMD)
Entity type:Individual
Prefix:
First Name:MANJULA
Middle Name:
Last Name:RAMANA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 AVERY PATH
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02459-3723
Mailing Address - Country:US
Mailing Address - Phone:781-710-3834
Mailing Address - Fax:
Practice Address - Street 1:1214 PARK ST
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-3738
Practice Address - Country:US
Practice Address - Phone:781-297-7360
Practice Address - Fax:781-297-7830
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA200531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2120372Medicaid