Provider Demographics
NPI:1053099507
Name:MINAMA, CHAITALI H
Entity type:Individual
Prefix:
First Name:CHAITALI
Middle Name:H
Last Name:MINAMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8777 PURDUE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-3104
Mailing Address - Country:US
Mailing Address - Phone:219-234-2345
Mailing Address - Fax:317-757-2877
Practice Address - Street 1:4512 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5836
Practice Address - Country:US
Practice Address - Phone:260-238-8899
Practice Address - Fax:260-755-3271
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014194A122300000X
NV8017122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty