Provider Demographics
NPI:1578678389
Name:SREENIVASAN, DEEPA (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:SREENIVASAN
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 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:SUITE 710
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3807
Mailing Address - Country:US
Mailing Address - Phone:310-216-5754
Mailing Address - Fax:
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:SUITE 710
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-216-5754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA509901223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry