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General NPI Number Information
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NPI Number | 1346061884
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Entity Type | Individual
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Provider Name | DEEPTHI NAMBALA BDS
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Gender | Female
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Dates
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Enumeration Date | 10/17/2024
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Last Update Date | 10/27/2024
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Provider Practice Location Address
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Address Line | SPECIAL HEALTHCARE NEEDS DENTAL CLINIC MALCOLM HEALTH SCIENCES MOOS TOWER, 515 DELAWARE ST. SE
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City | MINNEAPOLIS
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State | MN
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Zip | 55455
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Country | US
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Telephone | 612-625-4777
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Fax | 612-625-0613
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Provider Business Mailing Address
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Address Line | 19839 IRIS WAY
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City | LAKEVILLE
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State | MN
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Zip | 55044-3547
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Country | US
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Telephone | 425-351-0826
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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 | R890
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License Number State | MN
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