Provider Demographics
NPI:1265731632
Name:PETLURI, PRAVEENA
Entity type:Individual
Prefix:
First Name:PRAVEENA
Middle Name:
Last Name:PETLURI
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 1:46175 WESTLAKE DR STE 220
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20165-5884
Mailing Address - Country:US
Mailing Address - Phone:703-404-9111
Mailing Address - Fax:571-313-0501
Practice Address - Street 1:46175 WESTLAKE DR STE 220
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20165-5884
Practice Address - Country:US
Practice Address - Phone:703-404-9111
Practice Address - Fax:571-313-0501
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA04014123371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice