Provider Demographics
NPI:1174592786
Name:CHATURVEDULA, MYTREI (DMD)
Entity type:Individual
Prefix:
First Name:MYTREI
Middle Name:
Last Name:CHATURVEDULA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:PROVIDER ENROLLMENT 9TH FLOOR
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-559-8051
Mailing Address - Fax:
Practice Address - Street 1:111 GROSSMAN DR
Practice Address - Street 2:
Practice Address - City:BRAINTREE
Practice Address - State:MA
Practice Address - Zip Code:02184-4997
Practice Address - Country:US
Practice Address - Phone:781-849-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA203881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAX09110OtherBCBS - DENTAL
MAAA23419OtherHARVARD PILGRIM