Provider Demographics
NPI:1780833020
Name:VISWANATHAN, SHOBA (DDS)
Entity Type:Individual
Prefix:DR
First Name:SHOBA
Middle Name:
Last Name:VISWANATHAN
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 1:894 SIM HODGIN PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1931
Mailing Address - Country:US
Mailing Address - Phone:415-335-3537
Mailing Address - Fax:
Practice Address - Street 1:894 SIM HODGIN PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1931
Practice Address - Country:US
Practice Address - Phone:415-335-3537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-10
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012403A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist