Provider Demographics
NPI:1063056711
Name:RANJAN, PEEYUSH
Entity type:Individual
Prefix:
First Name:PEEYUSH
Middle Name:
Last Name:RANJAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1717 OLYMPIA WAY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-3929
Mailing Address - Country:US
Mailing Address - Phone:360-636-1900
Mailing Address - Fax:
Practice Address - Street 1:1717 OLYMPIA WAY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3929
Practice Address - Country:US
Practice Address - Phone:360-636-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE610072181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry