Provider Demographics
NPI:1912164013
Name:PALLAVI NARENDRANATH DDS
Entity Type:Organization
Organization Name:PALLAVI NARENDRANATH DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PALLAVI
Authorized Official - Middle Name:
Authorized Official - Last Name:NARENDRANATH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:585-924-7994
Mailing Address - Street 1:31 COBBLECREEK RD
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:NY
Mailing Address - Zip Code:14564-9763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1726
Practice Address - Country:US
Practice Address - Phone:315-331-3552
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-18
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY050826-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02627672Medicaid