Provider Demographics
NPI:1659705192
Name:SRINIVASA, SRINIKETH (DMD)
Entity Type:Individual
Prefix:DR
First Name:SRINIKETH
Middle Name:
Last Name:SRINIVASA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 E MIDLAND AVE
Mailing Address - Street 2:
Mailing Address - City:PARAMUS
Mailing Address - State:NJ
Mailing Address - Zip Code:07652-4116
Mailing Address - Country:US
Mailing Address - Phone:201-634-1476
Mailing Address - Fax:
Practice Address - Street 1:22 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4631
Practice Address - Country:US
Practice Address - Phone:201-333-0883
Practice Address - Fax:201-333-3225
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-31
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI02549700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist