Provider Demographics
NPI:1407256464
Name:SUBHADARSINI, SHYAMA (DDS, BDS)
Entity Type:Individual
Prefix:DR
First Name:SHYAMA
Middle Name:
Last Name:SUBHADARSINI
Suffix:
Gender:F
Credentials:DDS, BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4155 MOORPARK AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95117-1714
Mailing Address - Country:US
Mailing Address - Phone:408-249-7762
Mailing Address - Fax:
Practice Address - Street 1:4155 MOORPARK AVE STE 17
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95117-1714
Practice Address - Country:US
Practice Address - Phone:408-249-7762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63873122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist