Healthcare Provider Details

I. General information

NPI: 1700019767
Provider Name (Legal Business Name): GHAYATHRI RAVICHANDRAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 03/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 W. SEED FARM RD.
MESA AZ
85147-0038
US

IV. Provider business mailing address

P.O. BOX 38
SACATON AZ
85147-0038
US

V. Phone/Fax

Practice location:
  • Phone: 602-528-1200
  • Fax: 602-528-1255
Mailing address:
  • Phone: 602-528-1200
  • Fax: 602-528-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD 7859
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: