Provider Demographics
NPI:1134560808
Name:VAIDYANATHAN, VEENA (DDS)
Entity type:Individual
Prefix:
First Name:VEENA
Middle Name:
Last Name:VAIDYANATHAN
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 1:966C PARK ST # C
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-3650
Mailing Address - Country:US
Mailing Address - Phone:781-341-0030
Mailing Address - Fax:781-341-1166
Practice Address - Street 1:966C PARK ST # C
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-3650
Practice Address - Country:US
Practice Address - Phone:781-341-0030
Practice Address - Fax:781-341-1166
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010207771223G0001X
MADN18571071223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice