Provider Demographics
NPI:1851832091
Name:NANDHAVAN, IVANA (DMD)
Entity Type:Individual
Prefix:DR
First Name:IVANA
Middle Name:
Last Name:NANDHAVAN
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 1:106 MAIN ST STE 5
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-3362
Mailing Address - Country:US
Mailing Address - Phone:781-438-1003
Mailing Address - Fax:781-435-1996
Practice Address - Street 1:106 MAIN ST STE 5
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-3362
Practice Address - Country:US
Practice Address - Phone:781-438-1003
Practice Address - Fax:781-435-1996
Is Sole Proprietor?:No
Enumeration Date:2017-03-20
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18578481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice