Provider Demographics
NPI:1669788584
Name:SEETHARAM SHETTY, PRAVEENA (DMD)
Entity type:Individual
Prefix:DR
First Name:PRAVEENA
Middle Name:
Last Name:SEETHARAM SHETTY
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 1:160 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01901-1529
Mailing Address - Country:US
Mailing Address - Phone:781-593-1133
Mailing Address - Fax:
Practice Address - Street 1:160 MARKET ST
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01901-1529
Practice Address - Country:US
Practice Address - Phone:781-593-1133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855480122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist