MEDICARE: DR. SUPRIYA GOVERDHANAM BDS, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DE00010217	WA

General Provider Information

NPI Number	:	1528288461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUPRIYA GOVERDHANAM BDS, MS

Provider Business Mailing Address
First Line	:	291 C ST UNIT 112
Second Line	:
City	:	WASHOUGAL
State	:	WA
Zip	:	98671-2168
Country	:	US
Telephone Number	:	734-846-5153
Fax Number	:

Provider Business Practice Location Address
First Line	:	291 C ST UNIT 112
Second Line	:
City	:	WASHOUGAL
State	:	WA
Zip	:	98671-2168
Country	:	US
Telephone Number	:	734-846-5153
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	08/28/2008

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