Provider Demographics
NPI:1962133454
Name:PRAVEEN PAVULURU, DMD, LLC
Entity type:Organization
Organization Name:PRAVEEN PAVULURU, DMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PRAVEEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PAVULURU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-577-3424
Mailing Address - Street 1:90 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2652
Mailing Address - Country:US
Mailing Address - Phone:207-262-3744
Mailing Address - Fax:207-262-3745
Practice Address - Street 1:90 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2652
Practice Address - Country:US
Practice Address - Phone:207-262-3744
Practice Address - Fax:207-262-3745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-23
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental