Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0700X | Prosthodontist | 021002794 | IL |
N | 1223P0700X | Prosthodontist | 1001977 | WI |
NPI | 1215209366 |
---|---|
Provider Name | Dr. Sirisha Mandadi |
First Address | Naperville, IL 60564-1155 |
Second Address | Crest Hill, IL 60403-1881 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/02/2012 |
Last Update Date | 11/09/2019 |