Provider Demographics
NPI:1699938290
Name:MANDERA GOVINDAIAH, PRAVEEN KUMAR (DMD)
Entity type:Individual
Prefix:DR
First Name:PRAVEEN KUMAR
Middle Name:
Last Name:MANDERA GOVINDAIAH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 TECHNOLOGY DR
Mailing Address - Street 2:APT 4023
Mailing Address - City:NORTH CHELMSFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01863-2408
Mailing Address - Country:US
Mailing Address - Phone:781-526-1496
Mailing Address - Fax:
Practice Address - Street 1:281 SANDERS CREEK PARKWAY
Practice Address - Street 2:C/O ASPEN DENTAL MANAGEMENT CO., INC
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057
Practice Address - Country:US
Practice Address - Phone:800-966-6470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA222141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice