Provider Demographics
NPI:1871500611
Name:CANAKALAVENKATA, VIJAYALAKSHMI (DMD)
Entity Type:Individual
Prefix:DR
First Name:VIJAYALAKSHMI
Middle Name:
Last Name:CANAKALAVENKATA
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 1:860 HARRISON AVE
Mailing Address - Street 2:APT 1012
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4002
Mailing Address - Country:US
Mailing Address - Phone:617-504-0406
Mailing Address - Fax:
Practice Address - Street 1:66 KENNEDY PLZ
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-2004
Practice Address - Country:US
Practice Address - Phone:401-454-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN029321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice