Provider Demographics
NPI:1366476327
Name:MAKADIA, PRAVINCHANDRA K (DDS)
Entity Type:Individual
Prefix:
First Name:PRAVINCHANDRA
Middle Name:K
Last Name:MAKADIA
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 1:826 E MISSION BLVD
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2044
Mailing Address - Country:US
Mailing Address - Phone:909-622-1817
Mailing Address - Fax:909-622-8750
Practice Address - Street 1:826 E MISSION BLVD
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2044
Practice Address - Country:US
Practice Address - Phone:909-622-1817
Practice Address - Fax:909-622-8750
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52425Medicaid