Provider Demographics
NPI:1043496235
Name:CHANDRAN, RAVI (DMD PHD)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:
Last Name:CHANDRAN
Suffix:
Gender:M
Credentials:DMD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4915 LAVISTA RD
Mailing Address - Street 2:
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-8520
Mailing Address - Country:US
Mailing Address - Phone:709-341-9077
Mailing Address - Fax:770-493-4900
Practice Address - Street 1:4915 LAVISTA RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8520
Practice Address - Country:US
Practice Address - Phone:770-934-1907
Practice Address - Fax:770-493-4900
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3538-101223S0112X
GADN1225551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery