Provider Demographics
NPI:1053657494
Name:PAVAN, VANI (PERIODONTIST)
Entity Type:Individual
Prefix:
First Name:VANI
Middle Name:
Last Name:PAVAN
Suffix:
Gender:F
Credentials:PERIODONTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2805 E GRAPEVINE MILLS CIR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GRAPEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:76051-1210
Mailing Address - Country:US
Mailing Address - Phone:972-355-8688
Mailing Address - Fax:972-539-8389
Practice Address - Street 1:110 CHURCH ST
Practice Address - Street 2:
Practice Address - City:MARLIN
Practice Address - State:TX
Practice Address - Zip Code:76661-2809
Practice Address - Country:US
Practice Address - Phone:972-670-4991
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-12
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX285821223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1205490257Medicaid