Provider Demographics
NPI:1356654594
Name:PRAVEENA PERMALLA, DDS, INC
Entity Type:Organization
Organization Name:PRAVEENA PERMALLA, DDS, INC
Other - Org Name:PERMALLA DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEENA
Authorized Official - Middle Name:
Authorized Official - Last Name:PERMALLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-773-1234
Mailing Address - Street 1:855 LAKEVILLE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94952-7328
Mailing Address - Country:US
Mailing Address - Phone:707-773-1234
Mailing Address - Fax:
Practice Address - Street 1:855 LAKEVILLE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-7328
Practice Address - Country:US
Practice Address - Phone:707-773-1234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA549531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty