Provider Demographics
NPI:1881949592
Name:INDIRAMOHAN, AISHWARYA (DDS)
Entity type:Individual
Prefix:
First Name:AISHWARYA
Middle Name:
Last Name:INDIRAMOHAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5700 EDWARDS RANCH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4128
Mailing Address - Country:US
Mailing Address - Phone:817-292-2004
Mailing Address - Fax:178-292-7083
Practice Address - Street 1:802 N 9TH ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-6309
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:847-496-7603
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.029137122300000X
TX317731223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist