Provider Demographics
NPI:1023013919
Name:SIVA, KENNETH R (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:R
Last Name:SIVA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5847 FRANCIS LEWIS BLVD
Mailing Address - Street 2:STE 104
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364-1601
Mailing Address - Country:US
Mailing Address - Phone:718-428-2626
Mailing Address - Fax:718-631-9426
Practice Address - Street 1:5847 FRANCIS LEWIS BLVD
Practice Address - Street 2:STE 104
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-1601
Practice Address - Country:US
Practice Address - Phone:718-428-2626
Practice Address - Fax:718-631-9426
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY367221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice