Healthcare Provider Details

I. General information

NPI: 1003029489
Provider Name (Legal Business Name): THEYYAR RANGARAJAN D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 NW 9TH AVE
MULBERRY FL
33860-2922
US

IV. Provider business mailing address

47 5TH ST NW
WINTER HAVEN FL
33881-4672
US

V. Phone/Fax

Practice location:
  • Phone: 863-425-6200
  • Fax:
Mailing address:
  • Phone: 863-268-7850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN 14363
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: