Provider Demographics
NPI:1053370882
Name:MANDAVA, AMRUTHA CHANDRA (DMD)
Entity type:Individual
Prefix:DR
First Name:AMRUTHA
Middle Name:CHANDRA
Last Name:MANDAVA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1662 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205
Mailing Address - Country:US
Mailing Address - Phone:518-452-2121
Mailing Address - Fax:518-456-2865
Practice Address - Street 1:1662 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205
Practice Address - Country:US
Practice Address - Phone:518-452-2121
Practice Address - Fax:518-456-2865
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2009-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0424691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY795808OtherUNITED CONCORDIA