Provider Demographics
NPI:1487036646
Name:BALASUBRAMANIAN, PAVITHRA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PAVITHRA
Middle Name:
Last Name:BALASUBRAMANIAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:633 W RITTENHOUSE ST
Mailing Address - Street 2:APT# 226 B
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-4300
Mailing Address - Country:US
Mailing Address - Phone:412-874-2129
Mailing Address - Fax:
Practice Address - Street 1:248 S 21ST ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-5000
Practice Address - Country:US
Practice Address - Phone:215-732-3350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0404621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice