Provider Demographics
NPI:1851568893
Name:VASUDAVAN, SIVABALAN (BDSC MDSC MORTHRCS)
Entity Type:Individual
Prefix:DR
First Name:SIVABALAN
Middle Name:
Last Name:VASUDAVAN
Suffix:
Gender:M
Credentials:BDSC MDSC MORTHRCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:HUNNEWELL-4, MAIL STOP: HU-226
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-8702
Mailing Address - Fax:617-730-0478
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:HUNNEWELL-4, MAIL STOP: HU-226
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-8702
Practice Address - Fax:617-730-0478
Is Sole Proprietor?:No
Enumeration Date:2008-05-09
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA97341223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics