Provider Demographics
NPI:1679696884
Name:TIRUVALLUR, NANDINI (DMD)
Entity type:Individual
Prefix:DR
First Name:NANDINI
Middle Name:
Last Name:TIRUVALLUR
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 1:1101 SE TECH CENTER DR
Mailing Address - Street 2:SUITE 195
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-5504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10115 SW NIMBUS AVE
Practice Address - Street 2:SUITE 350
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-4349
Practice Address - Country:US
Practice Address - Phone:503-684-7868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD68041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice