Provider Demographics
NPI:1467516179
Name:VALLABHANENI, PRAVEEN CHOUDARI (DMD)
Entity Type:Individual
Prefix:DR
First Name:PRAVEEN
Middle Name:CHOUDARI
Last Name:VALLABHANENI
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 1:333 HOOSICK ST
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12180
Mailing Address - Country:US
Mailing Address - Phone:518-274-7001
Mailing Address - Fax:518-274-7016
Practice Address - Street 1:333 HOOSICK ST
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180
Practice Address - Country:US
Practice Address - Phone:518-274-7001
Practice Address - Fax:518-274-7016
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
BVS547724OtherDEA FEDERAL