Provider Demographics
NPI:1073125258
Name:SRIDHARAN, NISHA VASU (DMD)
Entity Type:Individual
Prefix:
First Name:NISHA
Middle Name:VASU
Last Name:SRIDHARAN
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 1:23978 ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-4314
Mailing Address - Country:US
Mailing Address - Phone:248-982-2476
Mailing Address - Fax:
Practice Address - Street 1:2429 ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-4853
Practice Address - Country:US
Practice Address - Phone:734-434-0043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-19
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901600602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist