Provider Demographics
NPI:1609505353
Name:PREM, SNEHA
Entity Type:Individual
Prefix:
First Name:SNEHA
Middle Name:
Last Name:PREM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:LYNNFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01940-1263
Mailing Address - Country:US
Mailing Address - Phone:617-359-2550
Mailing Address - Fax:
Practice Address - Street 1:12502 MUKILTEO SPEEDWAY STE 108
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5730
Practice Address - Country:US
Practice Address - Phone:425-374-1136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WADE613313971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program