Provider Demographics
NPI:1346970613
Name:RAVI PRAKASH, SASANKOTI MOHAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:SASANKOTI MOHAN
Middle Name:
Last Name:RAVI PRAKASH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 N IRBY ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-2808
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1362
Practice Address - Street 1:360 N IRBY ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-2808
Practice Address - Country:US
Practice Address - Phone:843-667-9414
Practice Address - Fax:843-667-1362
Is Sole Proprietor?:No
Enumeration Date:2022-06-10
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022020817122300000X
SC104631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist