Provider Demographics
NPI:1851951776
Name:SRIDHAR, PRIYA (BDS, DMD)
Entity Type:Individual
Prefix:
First Name:PRIYA
Middle Name:
Last Name:SRIDHAR
Suffix:
Gender:F
Credentials:BDS, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14027 LAKE CITY WAY NE APT E203
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98125-3856
Mailing Address - Country:US
Mailing Address - Phone:646-833-5637
Mailing Address - Fax:
Practice Address - Street 1:4122 FACTORIA BLVD SE STE 301
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-4277
Practice Address - Country:US
Practice Address - Phone:425-401-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-13
Last Update Date:2019-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60970475122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60970475OtherWASHINGTON STATE DEPARTMENT OF HEALTH