Provider Demographics
NPI:1275670937
Name:SREENIVASAN, SIVAKUMAR (DMD, MDS)
Entity Type:Individual
Prefix:DR
First Name:SIVAKUMAR
Middle Name:
Last Name:SREENIVASAN
Suffix:
Gender:M
Credentials:DMD, MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 S WASHINGTON ST STE 205
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2331
Mailing Address - Country:US
Mailing Address - Phone:301-294-8700
Mailing Address - Fax:301-294-9007
Practice Address - Street 1:77 S WASHINGTON ST STE 205
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-2331
Practice Address - Country:US
Practice Address - Phone:301-294-8700
Practice Address - Fax:301-294-9007
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD122421223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery