Provider Demographics
NPI:1508359902
Name:L SWAYAMPRAKASAM DDS CORP
Entity Type:Organization
Organization Name:L SWAYAMPRAKASAM DDS CORP
Other - Org Name:SEASIDE PERIO CENTRE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LOGESH
Authorized Official - Middle Name:
Authorized Official - Last Name:SWAYAMPRAKASAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-877-0645
Mailing Address - Street 1:3680 BEACON AVE APT B320
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-3033
Mailing Address - Country:US
Mailing Address - Phone:224-877-0645
Mailing Address - Fax:
Practice Address - Street 1:1550 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3154
Practice Address - Country:US
Practice Address - Phone:669-245-7494
Practice Address - Fax:669-265-0400
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1001401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty