Provider Demographics
NPI:1376215137
Name:MYSORE VISHWANATH, POORNIMA (DMD)
Entity Type:Individual
Prefix:DR
First Name:POORNIMA
Middle Name:
Last Name:MYSORE VISHWANATH
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 1:9 FIFER LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-1231
Mailing Address - Country:US
Mailing Address - Phone:512-674-5336
Mailing Address - Fax:
Practice Address - Street 1:314 MOODY ST
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02453-5202
Practice Address - Country:US
Practice Address - Phone:781-398-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859211122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist