Healthcare Provider Details

I. General information

NPI: 1770967093
Provider Name (Legal Business Name): DEEPA RAVICHANDRAN D.M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEEPA SELVAKUMAR

II. Dates (important events)

Enumeration Date: 07/16/2015
Last Update Date: 09/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 JOHN A CUMMINGS WAY
WOONSOCKET RI
02895-3244
US

IV. Provider business mailing address

25 JOHN A CUMMINGS WAY
WOONSOCKET RI
02895-3244
US

V. Phone/Fax

Practice location:
  • Phone: 401-767-4161
  • Fax: 401-767-5441
Mailing address:
  • Phone: 617-750-2135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN03477
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1856959
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: