Basic Information
| Provider Information | |||||||||
| NPI: | 1831192251 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNEM | ||||||||
| FirstName: | SASI | ||||||||
| MiddleName: | KALA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2103 MCHENRY AVENUE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094359550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2103 MCHENRY AVENUE | ||||||||
| Address2: | SUITE C | ||||||||
| City: | MODESTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094359550 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 19578 | TX | N | Dental Providers | Dentist | General Practice | 1223G0001X | 101387 | CA | Y | Dental Providers | Dentist | General Practice |
No ID Information.