Provider Demographics
NPI:1306003322
Name:PADAVETTAN, SUJATHA ANNADURAI (DDS)
Entity Type:Individual
Prefix:
First Name:SUJATHA
Middle Name:ANNADURAI
Last Name:PADAVETTAN
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 1:4530 BALFOUR RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513
Mailing Address - Country:US
Mailing Address - Phone:925-634-5061
Mailing Address - Fax:925-634-5865
Practice Address - Street 1:4530 BALFOUR RD
Practice Address - Street 2:SUITE C
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513
Practice Address - Country:US
Practice Address - Phone:925-634-5061
Practice Address - Fax:925-634-5865
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-19
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48657122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist