=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053657494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VANI PAVAN PERIODONTIST
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2012
-----------------------------------------------------
Last Update Date | 03/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 110 CHURCH ST
-----------------------------------------------------
City | MARLIN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76661-2809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-670-4991
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2805 E GRAPEVINE MILLS CIR SUITE 108
-----------------------------------------------------
City | GRAPEVINE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76051-1210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-355-8688
-----------------------------------------------------
Fax | 972-539-8389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 28582
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------