Provider Demographics
NPI:1972058709
Name:DIPTI SRIVASTAVA, PLLC
Entity Type:Organization
Organization Name:DIPTI SRIVASTAVA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DIPTI
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-369-9116
Mailing Address - Street 1:22619 SE 64TH PL STE 210
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5342
Mailing Address - Country:US
Mailing Address - Phone:425-369-9116
Mailing Address - Fax:425-369-8997
Practice Address - Street 1:22619 SE 64TH PL STE 210
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5342
Practice Address - Country:US
Practice Address - Phone:425-369-9116
Practice Address - Fax:425-369-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-22
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60034827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty