Healthcare Provider Details

I. General information

NPI: 1215044458
Provider Name (Legal Business Name): RAJ PANDE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335R PRAIRIE AVE
PROVIDENCE RI
02905-2426
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0430
  • Fax: 401-444-0489
Mailing address:
  • Phone: 401-444-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDEN03178
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12544
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number21146
License Number StateMA
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN03178
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: