Provider Demographics
NPI:1912096538
Name:CHANNEGOWDA, PAVITHRA KERAGOD (DDS)
Entity Type:Individual
Prefix:
First Name:PAVITHRA
Middle Name:KERAGOD
Last Name:CHANNEGOWDA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34158 KASPAR TER
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94555-2999
Mailing Address - Country:US
Mailing Address - Phone:510-724-2893
Mailing Address - Fax:
Practice Address - Street 1:39340 FREMONT BLVD
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1320
Practice Address - Country:US
Practice Address - Phone:510-739-3889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL50576122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist