Provider Demographics
NPI:1063821361
Name:RAJU, PRIYADARSHINI
Entity Type:Individual
Prefix:
First Name:PRIYADARSHINI
Middle Name:
Last Name:RAJU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 ADRIAN ST
Mailing Address - Street 2:APT 1
Mailing Address - City:SOMERVILLE
Mailing Address - State:MA
Mailing Address - Zip Code:02143-3907
Mailing Address - Country:US
Mailing Address - Phone:617-899-5217
Mailing Address - Fax:
Practice Address - Street 1:18 ADRIAN ST
Practice Address - Street 2:APT 1
Practice Address - City:SOMERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02143-3907
Practice Address - Country:US
Practice Address - Phone:617-899-5217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-12
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18566971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice