Provider Demographics
NPI:1962893115
Name:MADDATU DENTAL CORPORATION
Entity type:Organization
Organization Name:MADDATU DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MADDATU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-785-4282
Mailing Address - Street 1:14547 TITUS ST STE 207
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4932
Mailing Address - Country:US
Mailing Address - Phone:818-785-4282
Mailing Address - Fax:818-785-8704
Practice Address - Street 1:14547 TITUS ST STE 207
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4932
Practice Address - Country:US
Practice Address - Phone:818-785-4282
Practice Address - Fax:818-785-8704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-10
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55562122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty