Provider Demographics
NPI:1174805642
Name:MIDTHANA, SRINIVASA RAO
Entity type:Individual
Prefix:DR
First Name:SRINIVASA
Middle Name:RAO
Last Name:MIDTHANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 JUDSON ST
Mailing Address - Street 2:APT-4B
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08837-2436
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 EL PASEO RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD35951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice