Provider Demographics
NPI:1790083822
Name:PREMARAJ, THYAGASEELY (BDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:THYAGASEELY
Middle Name:
Last Name:PREMARAJ
Suffix:
Gender:F
Credentials:BDS, PHD
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 290370
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-7213
Practice Address - Fax:954-262-7355
Is Sole Proprietor?:No
Enumeration Date:2011-03-15
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1181223X0400X
FLDTP7161223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics