Provider Demographics
NPI:1558543132
Name:GORAVANCHI, BABAK (DDS)
Entity Type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:GORAVANCHI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11753 W BELLFORT SUITE 116
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77477
Mailing Address - Country:US
Mailing Address - Phone:713-446-8547
Mailing Address - Fax:713-467-9072
Practice Address - Street 1:11753 W BELLFORT ST STE 116
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:TX
Practice Address - Zip Code:77477-1327
Practice Address - Country:US
Practice Address - Phone:713-446-8547
Practice Address - Fax:713-467-9072
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX21389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158521802Medicaid