Provider Demographics
NPI:1790380160
Name:JANYAVULA, SRIDHAR (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:SRIDHAR
Middle Name:
Last Name:JANYAVULA
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 CARNEGIE CTR STE 360
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:NJ
Mailing Address - Zip Code:08540-6530
Mailing Address - Country:US
Mailing Address - Phone:713-447-7339
Mailing Address - Fax:
Practice Address - Street 1:2209 ELLIS DR
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-3405
Practice Address - Country:US
Practice Address - Phone:713-447-7339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-02
Last Update Date:2020-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0420491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty