Provider Demographics
NPI:1710150925
Name:RAJU, PRABHA R (DDS)
Entity Type:Individual
Prefix:
First Name:PRABHA
Middle Name:R
Last Name:RAJU
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 N GENESEE RD
Mailing Address - Street 2:P O BOX 90161
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1433
Mailing Address - Country:US
Mailing Address - Phone:810-715-3368
Mailing Address - Fax:810-715-1663
Practice Address - Street 1:1024 N GENESEE RD
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1433
Practice Address - Country:US
Practice Address - Phone:810-715-3368
Practice Address - Fax:810-715-1663
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI159241223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice