Provider Demographics
NPI:1528950813
Name:VENUGOPALAN, BHAVANA (DMD)
Entity type:Individual
Prefix:
First Name:BHAVANA
Middle Name:
Last Name:VENUGOPALAN
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 1:3483 WINTER CHASE DR
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-1221
Mailing Address - Country:US
Mailing Address - Phone:305-877-6352
Mailing Address - Fax:
Practice Address - Street 1:3384 COBB PKWY NW STE 130
Practice Address - Street 2:
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-8784
Practice Address - Country:US
Practice Address - Phone:678-574-8622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-19
Last Update Date:2025-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1238621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice