Provider Demographics
NPI:1780281949
Name:BHOLLA, PRADEEP KUMAR (DMD)
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:KUMAR
Last Name:BHOLLA
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 1:125 PLEASANT ST APT 401
Mailing Address - Street 2:
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-7180
Mailing Address - Country:US
Mailing Address - Phone:425-624-8172
Mailing Address - Fax:
Practice Address - Street 1:465 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01843-3526
Practice Address - Country:US
Practice Address - Phone:802-476-3171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN18588411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice