Provider Demographics
NPI:1417681198
Name:PRUTHI, SHIV (DMD, MPH)
Entity Type:Individual
Prefix:
First Name:SHIV
Middle Name:
Last Name:PRUTHI
Suffix:
Gender:M
Credentials:DMD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2651 BRAEBURN LN SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55902-3495
Mailing Address - Country:US
Mailing Address - Phone:507-993-8183
Mailing Address - Fax:
Practice Address - Street 1:1732 BROADWAY UNIT 101
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-2621
Practice Address - Country:US
Practice Address - Phone:206-785-1327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-10
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0115021223G0001X
WADE614785191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice