Provider Demographics
NPI:1760221386
Name:SPARK DENTAL LLC
Entity type:Organization
Organization Name:SPARK DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADHU VENKATA
Authorized Official - Middle Name:RAMA RAJU
Authorized Official - Last Name:NADIMPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MPA
Authorized Official - Phone:201-257-7095
Mailing Address - Street 1:12233 HAYLAND FARM WAY
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-6027
Mailing Address - Country:US
Mailing Address - Phone:201-257-7095
Mailing Address - Fax:
Practice Address - Street 1:18077 GARLAND GROH BLVD
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21740-2064
Practice Address - Country:US
Practice Address - Phone:301-888-8555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-22
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty