Healthcare Provider Details

I. General information

NPI: 1215209366
Provider Name (Legal Business Name): SIRISHA MANDADI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2012
Last Update Date: 09/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2241 THEODORE ST
CREST HILL IL
60403-1881
US

IV. Provider business mailing address

4627 CEDAR DR
NAPERVILLE IL
60564-1155
US

V. Phone/Fax

Practice location:
  • Phone: 815-741-1700
  • Fax: 815-741-8511
Mailing address:
  • Phone: 203-921-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number1001977
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number021002794
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: