Provider Demographics
NPI:1306622915
Name:RAVINDRA, SANJANA
Entity type:Individual
Prefix:
First Name:SANJANA
Middle Name:
Last Name:RAVINDRA
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 1:1912 GLENDON AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-4626
Mailing Address - Country:US
Mailing Address - Phone:415-967-8641
Mailing Address - Fax:
Practice Address - Street 1:750 E ALMOND AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-5617
Practice Address - Country:US
Practice Address - Phone:559-664-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0346171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice