Provider Demographics
NPI:1558535179
Name:GOBICHETTYPALAYAM, SATHISH L
Entity Type:Individual
Prefix:
First Name:SATHISH
Middle Name:L
Last Name:GOBICHETTYPALAYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-3111
Mailing Address - Country:US
Mailing Address - Phone:719-562-4461
Mailing Address - Fax:
Practice Address - Street 1:319 LYNNWAY
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1811
Practice Address - Country:US
Practice Address - Phone:781-599-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-15
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA220991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice