Provider Demographics
NPI:1295269116
Name:MONIKA SRIVASTAVA DMD PA WEST
Entity type:Organization
Organization Name:MONIKA SRIVASTAVA DMD PA WEST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SRIVASTAVA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:267-909-9551
Mailing Address - Street 1:18503 PINES BLVD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-1404
Mailing Address - Country:US
Mailing Address - Phone:954-436-0502
Mailing Address - Fax:954-436-0503
Practice Address - Street 1:18503 PINES BLVD
Practice Address - Street 2:SUITE 209
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33029-1404
Practice Address - Country:US
Practice Address - Phone:954-436-0502
Practice Address - Fax:954-436-0503
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2024-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003557500Medicaid