Provider Demographics
NPI:1124689302
Name:PRASAD GONAVARUM D.D.S., PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:PRASAD GONAVARUM D.D.S., PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GONAVARUM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:630-788-5833
Mailing Address - Street 1:7122 UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5926
Mailing Address - Country:US
Mailing Address - Phone:619-698-5471
Mailing Address - Fax:
Practice Address - Street 1:7122 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-5926
Practice Address - Country:US
Practice Address - Phone:619-698-5471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental