Provider Demographics
NPI:1831692425
Name:RAJENDRAN, LAVANYA (DMD)
Entity type:Individual
Prefix:
First Name:LAVANYA
Middle Name:
Last Name:RAJENDRAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 COPPER BEECH DR
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-2950
Mailing Address - Country:US
Mailing Address - Phone:203-379-7006
Mailing Address - Fax:
Practice Address - Street 1:190 HEMPSTEAD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6248
Practice Address - Country:US
Practice Address - Phone:860-443-2428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN036251223P0300X
CT12212390200000X
CT132491223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program