Provider Demographics
NPI:1770804007
Name:KHERA, AVANI S (DMD)
Entity type:Individual
Prefix:DR
First Name:AVANI
Middle Name:S
Last Name:KHERA
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 1:21 PEACE ST FL 2
Mailing Address - Street 2:ST JOSEPH'S HOSPITAL OF SPECIALTY CARE
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-1510
Mailing Address - Country:US
Mailing Address - Phone:401-456-4441
Mailing Address - Fax:
Practice Address - Street 1:21 PEACE ST FL 2
Practice Address - Street 2:ST. JOSEPH'S HOSPITAL OF SPECIALTY CARE
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-1510
Practice Address - Country:US
Practice Address - Phone:401-456-4441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18554121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300709Medicaid