Provider Demographics
NPI:1164677142
Name:KOTHANDAPANI, REVATHI (DDS)
Entity Type:Individual
Prefix:DR
First Name:REVATHI
Middle Name:
Last Name:KOTHANDAPANI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21061 GARDENA DR
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-1615
Mailing Address - Country:US
Mailing Address - Phone:408-646-3289
Mailing Address - Fax:
Practice Address - Street 1:193 ARCH ST
Practice Address - Street 2:SUITE B & C
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94062-1343
Practice Address - Country:US
Practice Address - Phone:650-369-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA564331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice