Provider Demographics
NPI:1831486356
Name:RENGASAMY VENUGOPALAN, SHANKAR (BDS, DDS, DMSC, PHD)
Entity Type:Individual
Prefix:
First Name:SHANKAR
Middle Name:
Last Name:RENGASAMY VENUGOPALAN
Suffix:
Gender:M
Credentials:BDS, DDS, DMSC, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1 KNEELAND ST FL 11
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1527
Mailing Address - Country:US
Mailing Address - Phone:617-636-6887
Mailing Address - Fax:617-636-0402
Practice Address - Street 1:1 KNEELAND ST FL 11
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02111-1527
Practice Address - Country:US
Practice Address - Phone:617-636-6887
Practice Address - Fax:617-636-0402
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA401871223X0400X
MADN18596791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics