Provider Demographics
NPI:1508179771
Name:RAVI, TANMYA STUTI (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANMYA
Middle Name:STUTI
Last Name:RAVI
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 1:12300 S SHORE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-6509
Mailing Address - Country:US
Mailing Address - Phone:561-204-4494
Mailing Address - Fax:
Practice Address - Street 1:12300 S SHORE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-6509
Practice Address - Country:US
Practice Address - Phone:561-204-4494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH037911223G0001X
FLDN200331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice