Healthcare Provider Details

I. General information

NPI: 1417804907
Provider Name (Legal Business Name): JYOTHIRMAYI MAMIDI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2026
Last Update Date: 03/13/2026
Certification Date: 03/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4600 ROSWELL RD UNIT C120
SANDY SPRINGS GA
30342-3189
US

IV. Provider business mailing address

3812 MINE CREEK LN
MARIETTA GA
30062-5884
US

V. Phone/Fax

Practice location:
  • Phone: 404-341-9593
  • Fax:
Mailing address:
  • Phone: 216-534-6237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN124083
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: