Provider Demographics
NPI:1629309042
Name:PRAKASH, PREETI
Entity Type:Individual
Prefix:
First Name:PREETI
Middle Name:
Last Name:PRAKASH
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 1:2524 W MEMORY LN
Mailing Address - Street 2:
Mailing Address - City:PORTERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:93257-6929
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:476 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EARLIMART
Practice Address - State:CA
Practice Address - Zip Code:93219
Practice Address - Country:US
Practice Address - Phone:661-849-2781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-25
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25138122300000X
CA57702122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist