Provider Demographics
NPI:1801825484
Name:BANAHATTI, PRIYA (DMD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:BANAHATTI
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 1:50 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:285 JAMES STREET
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424
Practice Address - Country:US
Practice Address - Phone:616-738-8978
Practice Address - Fax:616-738-9127
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2011-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901018573122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4554740Medicaid