Provider Demographics
NPI:1720196173
Name:THANKACHEN, PAVITHRA SHETTY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PAVITHRA
Middle Name:SHETTY
Last Name:THANKACHEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:PAVITHRA
Other - Middle Name:G
Other - Last Name:SHETTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2131 EAST COAST HWY SUITE 220
Mailing Address - Street 2:
Mailing Address - City:CORONA DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92625-3421
Mailing Address - Country:US
Mailing Address - Phone:949-644-1001
Mailing Address - Fax:
Practice Address - Street 1:2131 EAST COAST HWY SUITE 220
Practice Address - Street 2:
Practice Address - City:CORONA DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92625-3421
Practice Address - Country:US
Practice Address - Phone:949-644-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-27
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51522122300000X, 1223G0001X
NY05185611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA51522Medicaid