Provider Demographics
NPI:1891109765
Name:PURANIK, CHAITANYA PRAKASH (BDS, MS, MDS, PHD)
Entity Type:Individual
Prefix:DR
First Name:CHAITANYA
Middle Name:PRAKASH
Last Name:PURANIK
Suffix:
Gender:M
Credentials:BDS, MS, MDS, PHD
Other - Prefix:
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Mailing Address - Street 1:13123 E 16TH AVE # B240
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80045-7106
Mailing Address - Country:US
Mailing Address - Phone:720-777-6788
Mailing Address - Fax:720-777-7354
Practice Address - Street 1:13123 E 16TH AVE STOP B240
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80045
Practice Address - Country:US
Practice Address - Phone:720-777-2719
Practice Address - Fax:720-777-7354
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2018-11-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA04014160881223P0221X
TX338601223P0221X
CT390200000X
COAD.00005191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000165418Medicaid