Provider Demographics
NPI:1518028752
Name:GANESH, PRAVEENA (DMD)
Entity Type:Individual
Prefix:DR
First Name:PRAVEENA
Middle Name:
Last Name:GANESH
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 1:169 VIA MAGNOLIA
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-6970
Mailing Address - Country:US
Mailing Address - Phone:805-498-1529
Mailing Address - Fax:
Practice Address - Street 1:200 S WELLS RD
Practice Address - Street 2:#200
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1377
Practice Address - Country:US
Practice Address - Phone:805-659-1740
Practice Address - Fax:805-659-3217
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist