=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962133454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRAVEEN PAVULURU, DMD, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2022
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 RIDGEWOOD DR
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-2652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-262-3744
-----------------------------------------------------
Fax | 207-262-3745
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 RIDGEWOOD DR
-----------------------------------------------------
City | BANGOR
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04401-2652
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-262-3744
-----------------------------------------------------
Fax | 207-262-3745
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE OWNER/MEMBER
-----------------------------------------------------
Name | DR. PRAVEEN K PAVULURU
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 207-577-3424
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------