Provider Demographics
NPI:1740433267
Name:BANDA, PRAVEEN R (DMD)
Entity Type:Individual
Prefix:
First Name:PRAVEEN
Middle Name:R
Last Name:BANDA
Suffix:
Gender:M
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:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:
Practice Address - Street 1:20 COMMERCE WAY
Practice Address - Street 2:
Practice Address - City:SEEKONK
Practice Address - State:MA
Practice Address - Zip Code:02771-5823
Practice Address - Country:US
Practice Address - Phone:508-336-6700
Practice Address - Fax:508-336-6742
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice