Provider Demographics
NPI:1912094749
Name:DOCTOR, RAVI VASANT (DDS)
Entity Type:Individual
Prefix:DR
First Name:RAVI
Middle Name:VASANT
Last Name:DOCTOR
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1810 SOUTH BOWEN ROAD SUITE #A
Mailing Address - Street 2:
Mailing Address - City:PANTEGO
Mailing Address - State:TX
Mailing Address - Zip Code:76013
Mailing Address - Country:US
Mailing Address - Phone:817-274-8667
Mailing Address - Fax:817-274-5238
Practice Address - Street 1:1810 SOUTH BOWEN ROAD SUITE #A
Practice Address - Street 2:
Practice Address - City:PANTEGO
Practice Address - State:TX
Practice Address - Zip Code:76013
Practice Address - Country:US
Practice Address - Phone:817-274-8667
Practice Address - Fax:817-274-5238
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX153071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice