Provider Demographics
NPI:1851626675
Name:VENKATESHAIAN, PALLAVI (DDS)
Entity Type:Individual
Prefix:
First Name:PALLAVI
Middle Name:
Last Name:VENKATESHAIAN
Suffix:
Gender:F
Credentials:DDS
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 1:4459 E BLUE GRASS RD
Practice Address - Street 2:SUITE D
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-9697
Practice Address - Country:US
Practice Address - Phone:989-773-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI24840131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice