Provider Demographics
NPI:1386428605
Name:AYANAMBAKKAM PANDURANGAN BEGAN, THENDRAL
Entity type:Individual
Prefix:
First Name:THENDRAL
Middle Name:
Last Name:AYANAMBAKKAM PANDURANGAN BEGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:THENDRAL
Other - Middle Name:
Other - Last Name:BEGAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:2267 S KOKE MILL RD UNIT C
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62711-8088
Mailing Address - Country:US
Mailing Address - Phone:347-589-3214
Mailing Address - Fax:
Practice Address - Street 1:3820 WABASH AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62711-6467
Practice Address - Country:US
Practice Address - Phone:217-698-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0345741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice