Provider Demographics
NPI:1407074370
Name:SRINIVAS, SHUBHA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHUBHA
Middle Name:
Last Name:SRINIVAS
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 1:1509 WASHINGTON ST STE D
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-5612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1509 WASHINGTON ST STE D
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-5612
Practice Address - Country:US
Practice Address - Phone:989-837-9740
Practice Address - Fax:989-837-3672
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2011-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010194691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice