Provider Demographics
NPI:1003104886
Name:TRIVEDI, AMAR (DDS)
Entity type:Individual
Prefix:
First Name:AMAR
Middle Name:
Last Name:TRIVEDI
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 SHADOW OAKS DR
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-6070
Mailing Address - Country:US
Mailing Address - Phone:281-515-6155
Mailing Address - Fax:
Practice Address - Street 1:8202 FM 3180 RD
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77523-1424
Practice Address - Country:US
Practice Address - Phone:281-231-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA09184122300000X
PA040428122300000X
MDLL9001223P0221X
TX272191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid