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General NPI Number Information
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NPI Number | 1134973290
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Entity Type | Individual
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Provider Name | MEGHANA MANTHA DMD
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Gender | Female
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Dates
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Enumeration Date | 04/15/2024
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Last Update Date | 06/09/2024
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Provider Practice Location Address
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Address Line | 5240 FRANKLIN ST
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City | MICHIGAN CITY
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State | IN
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Zip | 46360-7372
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Country | US
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Telephone | 219-873-9000
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Fax |
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Provider Business Mailing Address
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Address Line | 19W235 GLOUCESTER WAY N
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City | OAK BROOK
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State | IL
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Zip | 60523-1004
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Country | US
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Telephone | 703-786-4345
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12014455A
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License Number State | IN
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Taxonomy #2
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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