Provider Demographics
NPI:1528093135
Name:RAGHAVENDRA, SREE (DMD)
Entity type:Individual
Prefix:
First Name:SREE
Middle Name:
Last Name:RAGHAVENDRA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:MC3905
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-3905
Mailing Address - Country:US
Mailing Address - Phone:860-679-2207
Mailing Address - Fax:860-679-1899
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-1000
Practice Address - Country:US
Practice Address - Phone:860-679-3415
Practice Address - Fax:860-679-7507
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0091761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236354Medicaid