Healthcare Provider Details

I. General information

NPI: 1760612857
Provider Name (Legal Business Name): DESH DEEP MANDHYAN D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 08/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 UNION ST
LYNN MA
01901-1310
US

IV. Provider business mailing address

26 WORCESTER ST APT 101
BOSTON MA
02118-3322
US

V. Phone/Fax

Practice location:
  • Phone: 781-592-9250
  • Fax:
Mailing address:
  • Phone: 405-219-1760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1855224
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number010347
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: