Provider Demographics
NPI:1447355276
Name:PAMIDIMUKKALA, DHEERAJ (DMD)
Entity type:Individual
Prefix:DR
First Name:DHEERAJ
Middle Name:
Last Name:PAMIDIMUKKALA
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 1:100 CLEARWATER DR
Mailing Address - Street 2:#75
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1317
Mailing Address - Country:US
Mailing Address - Phone:617-642-9775
Mailing Address - Fax:
Practice Address - Street 1:315 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2179
Practice Address - Country:US
Practice Address - Phone:207-797-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice