Provider Demographics
NPI:1649706391
Name:KANWAR, RAVEENA (DMD)
Entity type:Individual
Prefix:
First Name:RAVEENA
Middle Name:
Last Name:KANWAR
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1820 PROFESSIONAL DR STE 5
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-2120
Mailing Address - Country:US
Mailing Address - Phone:916-483-8182
Mailing Address - Fax:
Practice Address - Street 1:1820 PROFESSIONAL DR STE 5
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-483-8182
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-02
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025517122300000X
CA103679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist