Provider Demographics
NPI:1528288461
Name:GOVERDHANAM, SUPRIYA (BDS, MS)
Entity type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:GOVERDHANAM
Suffix:
Gender:F
Credentials:BDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:291 C ST UNIT 112
Mailing Address - Street 2:
Mailing Address - City:WASHOUGAL
Mailing Address - State:WA
Mailing Address - Zip Code:98671-2168
Mailing Address - Country:US
Mailing Address - Phone:734-846-5153
Mailing Address - Fax:
Practice Address - Street 1:291 C ST UNIT 112
Practice Address - Street 2:
Practice Address - City:WASHOUGAL
Practice Address - State:WA
Practice Address - Zip Code:98671-2168
Practice Address - Country:US
Practice Address - Phone:734-846-5153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2008-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00010217122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist