Provider Demographics
NPI:1932816501
Name:HEALTHY DENTAL OF EASTERN AVENUE LLC
Entity type:Organization
Organization Name:HEALTHY DENTAL OF EASTERN AVENUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHU VENKATA
Authorized Official - Middle Name:RAMA RAJU
Authorized Official - Last Name:NADIMPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MPA
Authorized Official - Phone:201-257-7095
Mailing Address - Street 1:12233 HAYLAND FARM WAY
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6027
Mailing Address - Country:US
Mailing Address - Phone:201-257-7095
Mailing Address - Fax:
Practice Address - Street 1:7422 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-1923
Practice Address - Country:US
Practice Address - Phone:410-888-0888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-02
Last Update Date:2022-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty