Provider Demographics
NPI:1356455034
Name:SHETTY, DIVYA Y (DMD)
Entity Type:Individual
Prefix:MRS
First Name:DIVYA
Middle Name:Y
Last Name:SHETTY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 BARBARA JORDAN BLVD
Mailing Address - Street 2:SUITE 1435
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3083
Mailing Address - Country:US
Mailing Address - Phone:512-467-9955
Mailing Address - Fax:512-322-9966
Practice Address - Street 1:1201 BARBARA JORDAN BLVD
Practice Address - Street 2:SUITE 1435
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3083
Practice Address - Country:US
Practice Address - Phone:512-467-9955
Practice Address - Fax:512-322-9966
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2010-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2040229701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice