Healthcare Provider Details

I. General information

NPI: 1831692425
Provider Name (Legal Business Name): LAVANYA RAJENDRAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 HEMPSTEAD ST
NEW LONDON CT
06320-6248
US

IV. Provider business mailing address

25 COPPER BEECH DR
CHESHIRE CT
06410-2950
US

V. Phone/Fax

Practice location:
  • Phone: 860-443-2428
  • Fax:
Mailing address:
  • Phone: 203-379-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDEN03625
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number12212
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number13249
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: