Provider Demographics
NPI:1285202796
Name:VENKATACHALAM, SIVAKUMAR (DMD)
Entity Type:Individual
Prefix:DR
First Name:SIVAKUMAR
Middle Name:
Last Name:VENKATACHALAM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3837 PEPPER TREE LN APT 6208
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:34785-7600
Mailing Address - Country:US
Mailing Address - Phone:706-332-6696
Mailing Address - Fax:
Practice Address - Street 1:4675 E SR 44 STE 104
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:FL
Practice Address - Zip Code:34785-7461
Practice Address - Country:US
Practice Address - Phone:352-418-3041
Practice Address - Fax:352-502-4141
Is Sole Proprietor?:No
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN258901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice