Provider Demographics
NPI:1326191321
Name:SHIVARAM, CHETAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHETAN
Middle Name:
Last Name:SHIVARAM
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 1:301 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88001-3667
Mailing Address - Country:US
Mailing Address - Phone:505-524-4900
Mailing Address - Fax:505-524-8300
Practice Address - Street 1:301 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88001-3667
Practice Address - Country:US
Practice Address - Phone:505-524-4900
Practice Address - Fax:505-524-8300
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD24801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N0238Medicaid
NM164588Medicaid