Provider Demographics
NPI:1194999375
Name:PRASAD GONAVARUM D.D.S., P.C.
Entity type:Organization
Organization Name:PRASAD GONAVARUM D.D.S., P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:
Authorized Official - Last Name:GONAVARUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-718-1901
Mailing Address - Street 1:3020 REFLECTION DR
Mailing Address - Street 2:SUITE : 112
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8243
Mailing Address - Country:US
Mailing Address - Phone:630-718-1901
Mailing Address - Fax:
Practice Address - Street 1:3020 REFLECTION DR
Practice Address - Street 2:SUITE : 112
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-8243
Practice Address - Country:US
Practice Address - Phone:630-718-1901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-17
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty