Provider Demographics
NPI:1053629543
Name:SISTA, SRIVALLI PURNIMA (DMD)
Entity Type:Individual
Prefix:
First Name:SRIVALLI
Middle Name:PURNIMA
Last Name:SISTA
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 1:1338 VETERANS HWY
Mailing Address - Street 2:APT H # 5
Mailing Address - City:LEVITTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19056-2025
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2107 B COTTMAN AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19149
Practice Address - Country:US
Practice Address - Phone:215-235-4060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2010-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS038492122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist