Provider Demographics
NPI:1336345115
Name:PADMANABHA, RAVI PATRICK (DDS)
Entity type:Individual
Prefix:DR
First Name:RAVI
Middle Name:PATRICK
Last Name:PADMANABHA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:LE ROY
Mailing Address - State:NY
Mailing Address - Zip Code:14482-1046
Mailing Address - Country:US
Mailing Address - Phone:585-768-6060
Mailing Address - Fax:585-768-2211
Practice Address - Street 1:20 LAKE ST
Practice Address - Street 2:
Practice Address - City:LE ROY
Practice Address - State:NY
Practice Address - Zip Code:14482-1046
Practice Address - Country:US
Practice Address - Phone:585-768-6060
Practice Address - Fax:585-768-2211
Is Sole Proprietor?:No
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047513122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist