Provider Demographics
NPI:1639127384
Name:PANCHOLI, CHANDRAVADAN (DDS)
Entity Type:Individual
Prefix:
First Name:CHANDRAVADAN
Middle Name:
Last Name:PANCHOLI
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 1:29753 HOOVER RD
Mailing Address - Street 2:B
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-8900
Mailing Address - Country:US
Mailing Address - Phone:586-573-0011
Mailing Address - Fax:
Practice Address - Street 1:29753 HOOVER RD
Practice Address - Street 2:B
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-8900
Practice Address - Country:US
Practice Address - Phone:586-573-0011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901016165122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist