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General NPI Number Information
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NPI Number | 1962893115
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Entity Type | Organization
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Legal Business Name | MADDATU DENTAL CORPORATION
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 05/30/2015
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Provider Practice Location Address
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Address Line | 14547 TITUS ST STE 207
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City | PANORAMA CITY
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State | CA
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Zip | 91402-4932
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Country | US
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Telephone | 818-785-4282
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Fax | 818-785-8704
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Provider Business Mailing Address
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Address Line | 14547 TITUS ST STE 207
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City | PANORAMA CITY
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State | CA
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Zip | 91402-4932
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Country | US
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Telephone | 818-785-4282
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Fax | 818-785-8704
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Authorized Official
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Title or Position | DENTIST/ OWNER
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Name | DR. JONATHAN L MADDATU
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Credential | DDS
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Telephone | 818-785-4282
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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 | 55562
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License Number State | CA
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