Provider Demographics
NPI:1659090470
Name:CHANDRADHARA, BHAVANA (DMD)
Entity Type:Individual
Prefix:DR
First Name:BHAVANA
Middle Name:
Last Name:CHANDRADHARA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1455 COMMONWEALTH AVE APT 510
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3610
Mailing Address - Country:US
Mailing Address - Phone:617-816-3489
Mailing Address - Fax:
Practice Address - Street 1:1322 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:NATICK
Practice Address - State:MA
Practice Address - Zip Code:01760-1501
Practice Address - Country:US
Practice Address - Phone:508-439-6006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-24
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist