Provider Demographics
NPI:1619066115
Name:RAVAL, AMITA P
Entity Type:Individual
Prefix:DR
First Name:AMITA
Middle Name:P
Last Name:RAVAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 BOULDER HILL PASS
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:IL
Mailing Address - Zip Code:60538-1951
Mailing Address - Country:US
Mailing Address - Phone:630-896-5013
Mailing Address - Fax:630-896-5108
Practice Address - Street 1:20 BOULDER HILL PASS
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:IL
Practice Address - Zip Code:60538-1951
Practice Address - Country:US
Practice Address - Phone:630-896-5013
Practice Address - Fax:630-896-5108
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024639122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist