1801825484 NPI number — PRIYA BANAHATTI DMD

Table of content: PRIYA BANAHATTI DMD (NPI 1801825484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801825484 NPI number — PRIYA BANAHATTI DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BANAHATTI
Provider First Name:
PRIYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801825484
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 INDUSTRIAL PARK DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BANGOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-427-7937
Provider Business Mailing Address Fax Number:
269-427-5180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
285 JAMES STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49424
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-738-8978
Provider Business Practice Location Address Fax Number:
616-738-9127
Provider Enumeration Date:
07/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  2901018573 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 4554740 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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