Provider Demographics
NPI:1295923654
Name:CHELLAMUTHU, PRAVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:PRAVIN
Middle Name:
Last Name:CHELLAMUTHU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 NORTHAMPTON ST
Mailing Address - Street 2:APT # 2105
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02118-4014
Mailing Address - Country:US
Mailing Address - Phone:857-753-7213
Mailing Address - Fax:
Practice Address - Street 1:500 SOUTH ST W
Practice Address - Street 2:
Practice Address - City:RAYNHAM
Practice Address - State:MA
Practice Address - Zip Code:02767-5342
Practice Address - Country:US
Practice Address - Phone:508-821-1428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22008122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist