Provider Demographics
NPI:1215355300
Name:DESAI, PRAVIN R (DDS)
Entity Type:Individual
Prefix:
First Name:PRAVIN
Middle Name:R
Last Name:DESAI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4127 GAGE AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-1128
Mailing Address - Country:US
Mailing Address - Phone:323-773-2931
Mailing Address - Fax:323-773-2933
Practice Address - Street 1:4127 GAGE AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-1128
Practice Address - Country:US
Practice Address - Phone:323-773-2931
Practice Address - Fax:323-773-2933
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28537122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist