Provider Demographics
NPI:1912354689
Name:AGRAWAL, PRIYADARSHINI
Entity Type:Individual
Prefix:
First Name:PRIYADARSHINI
Middle Name:
Last Name:AGRAWAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 LANGPORT DR
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-4677
Mailing Address - Country:US
Mailing Address - Phone:650-669-4462
Mailing Address - Fax:
Practice Address - Street 1:1890 WAITE ST STE 1
Practice Address - Street 2:
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-23
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD00150122300000X
ORD11822122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist