Provider Demographics
NPI:1023635232
Name:VALISHETTY, MAMATHA
Entity type:Individual
Prefix:
First Name:MAMATHA
Middle Name:
Last Name:VALISHETTY
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 1:755 STATE HIGHWAY 121 BYP # A200
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-8189
Mailing Address - Country:US
Mailing Address - Phone:732-207-9775
Mailing Address - Fax:
Practice Address - Street 1:755 STATE HIGHWAY 121 BYP # A200
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-8189
Practice Address - Country:US
Practice Address - Phone:732-207-9775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-03
Last Update Date:2024-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37719122300000X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist