Healthcare Provider Details

I. General information

NPI: 1376144915
Provider Name (Legal Business Name): DR. PRATHYUSHA CHAVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/02/2020
Last Update Date: 11/02/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3882 S CLACK ST
ABILENE TX
79606-2711
US

IV. Provider business mailing address

55 STATION LNDG APT 215
MEDFORD MA
02155-5008
US

V. Phone/Fax

Practice location:
  • Phone: 325-695-1500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number36837
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: