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General NPI Number Information
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NPI Number | 1255498861
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Entity Type | Individual
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Provider Name | MAMATA MUKKARA DMD, DSCD, CAGS
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Gender | Female
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 06/14/2019
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Provider Practice Location Address
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Address Line | 5632 THE ALAMEDA
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City | BALTIMORE
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State | MD
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Zip | 21239-2737
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Country | US
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Telephone | 617-480-2348
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Fax |
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Provider Business Mailing Address
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Address Line | 2221 E BIJOU ST STE 100
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City | COLORADO SPRINGS
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State | CO
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Zip | 80909-8009
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Country | US
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Telephone | 719-576-1850
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Fax | 719-955-3470
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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 | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 15876
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License Number State | MD
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