Provider Demographics
NPI:1255510624
Name:RAKESH, PALLAVI T (DMD)
Entity type:Individual
Prefix:MRS
First Name:PALLAVI
Middle Name:T
Last Name:RAKESH
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 1:3357 MARLA BLVD NW
Mailing Address - Street 2:
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30092-6655
Mailing Address - Country:US
Mailing Address - Phone:404-963-8858
Mailing Address - Fax:
Practice Address - Street 1:4046 WETHERBURN WAY
Practice Address - Street 2:SUITE3
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30092-4660
Practice Address - Country:US
Practice Address - Phone:770-368-3297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2007-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN013589122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist