Provider Demographics
NPI:1992803571
Name:ADATROW, PRADEEP (DDS)
Entity type:Individual
Prefix:DR
First Name:PRADEEP
Middle Name:
Last Name:ADATROW
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 1:7135 GETWELL RD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-9659
Mailing Address - Country:US
Mailing Address - Phone:662-655-4868
Mailing Address - Fax:
Practice Address - Street 1:7135 GETWELL RD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-9659
Practice Address - Country:US
Practice Address - Phone:662-655-4868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPER-505-161223P0300X
TN85861223P0700X, 1223P0300X
MSPROS-504-161223P0700X
MS3727-13122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223P0300XDental ProvidersDentistPeriodontics
No1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS3727-13OtherDENTAL LICENSE