Provider Demographics
NPI:1184832164
Name:SRINIVASAN, BALAJI (DDS)
Entity Type:Individual
Prefix:DR
First Name:BALAJI
Middle Name:
Last Name:SRINIVASAN
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 1:26 BRENTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BAYVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08721-2159
Mailing Address - Country:US
Mailing Address - Phone:732-606-9194
Mailing Address - Fax:
Practice Address - Street 1:1700 MADISON AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1253
Practice Address - Country:US
Practice Address - Phone:732-363-5370
Practice Address - Fax:732-364-5684
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI194111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice