Provider Demographics
NPI:1346490034
Name:DURVASULA, MADHAVI (DDS)
Entity Type:Individual
Prefix:MRS
First Name:MADHAVI
Middle Name:
Last Name:DURVASULA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1063 MORSE AVE APT 8-100
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94089-1666
Mailing Address - Country:US
Mailing Address - Phone:408-734-0260
Mailing Address - Fax:
Practice Address - Street 1:1063 MORSE AVE APT 8-100
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94089-1666
Practice Address - Country:US
Practice Address - Phone:408-734-0260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA576761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice