Provider Demographics
NPI:1942818182
Name:PATTABHI, PRASANTHI
Entity Type:Individual
Prefix:
First Name:PRASANTHI
Middle Name:
Last Name:PATTABHI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 LAWRENCEVILLE SUWANEE RD STE C
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-8741
Mailing Address - Country:US
Mailing Address - Phone:470-582-9678
Mailing Address - Fax:
Practice Address - Street 1:1165 LAWRENCEVILLE SUWANEE RD STE C
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-8741
Practice Address - Country:US
Practice Address - Phone:470-582-9678
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9696122300000X
GADN1223071223G0001X
IL019.032725122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist