Provider Demographics
NPI:1073098018
Name:SRINIVASULA, VIDARSHANA
Entity Type:Individual
Prefix:
First Name:VIDARSHANA
Middle Name:
Last Name:SRINIVASULA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2312 AUGUSTA PL
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95051-1718
Mailing Address - Country:US
Mailing Address - Phone:408-585-8691
Mailing Address - Fax:
Practice Address - Street 1:2312 AUGUSTA PL
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95051-1718
Practice Address - Country:US
Practice Address - Phone:408-585-8691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS103240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist