Provider Demographics
NPI:1376990077
Name:RAVURI, SUSEE PRIYANKA (BDS, MPA, MSD)
Entity Type:Individual
Prefix:MISS
First Name:SUSEE PRIYANKA
Middle Name:
Last Name:RAVURI
Suffix:
Gender:F
Credentials:BDS, MPA, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N MERIDIAN STE A104
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-4409
Mailing Address - Country:US
Mailing Address - Phone:619-300-9832
Mailing Address - Fax:
Practice Address - Street 1:1002 N MERIDIAN STE A104
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98371-4409
Practice Address - Country:US
Practice Address - Phone:619-300-9832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014158711223G0001X
390200000X
WADE607298001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program