Provider Demographics
NPI:1710265434
Name:DURSHANAPALLI, SRINIVAS R
Entity Type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:R
Last Name:DURSHANAPALLI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 N CYPRESS DR
Mailing Address - Street 2:APT#3405
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-3376
Mailing Address - Country:US
Mailing Address - Phone:203-215-4687
Mailing Address - Fax:
Practice Address - Street 1:1403 W GLEN AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4705
Practice Address - Country:US
Practice Address - Phone:309-692-4721
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-29
Last Update Date:2013-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028802122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist