Heera Govindarajan Venguidesvarane, DDS
Individual provider Active NPI Dentist · Othello, WA
NPI 1003548611 · NPPES record last updated Jun 17, 2024
Key facts
- NPI
- 1003548611
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- DE61326176 (WA)
- Practice address
- 1515 E Columbia St
Othello, WA 99344-1846 - Phone
- (509) 488-5256
- Fax
- (509) 488-9939
- NPI assigned
- Jun 30, 2022
- Sex
- Female
- Sole proprietor
- No
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in WA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: No · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20230103001388 | WA | Order and Referring Only - Dentist |
9931579257 |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
Networks
- WA PPO C-SNP
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | DE61326176 | WA | Yes |
Addresses
Primary practice location
1515 E Columbia St
Othello, WA 99344-1846
Mailing address
1515 E Columbia St
Othello, WA 99344-1846
Phone (509) 488-5256
Other practice location 1
601 Government Rd
Mattawa, WA 99349-5120
Phone (509) 488-5256
Other practice location 2
1051 Columbia Ave
Connell, WA 99326-8702
Phone (509) 488-5256
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| DE61326176 | Other | WA | DOH LICENSE |
Other providers in Othello, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 17, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.