MEDICARE: DR. PADMAJA K MUTYALA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	54081	CA

General Provider Information

NPI Number	:	1811965114
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PADMAJA K MUTYALA DDS

Provider Business Mailing Address
First Line	:	11311 CRABBET PARK DR
Second Line	:
City	:	BAKERSFIELD
State	:	CA
Zip	:	93311-9227
Country	:	US
Telephone Number	:	661-663-9221
Fax Number	:

Provider Business Practice Location Address
First Line	:	13029 STOCKDALE HWY
Second Line	:	SUITE 100
City	:	BAKERSFIELD
State	:	CA
Zip	:	93314-9589
Country	:	US
Telephone Number	:	661-829-7905
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/10/2006
Last Update Date	:	08/03/2012

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