Provider Demographics
NPI:1932376779
Name:KOLLA, SIVA PRAKASH (DDS)
Entity Type:Individual
Prefix:
First Name:SIVA
Middle Name:PRAKASH
Last Name:KOLLA
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 1:8316 W BURROUGHS RD
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-9764
Mailing Address - Country:US
Mailing Address - Phone:425-628-5353
Mailing Address - Fax:
Practice Address - Street 1:16657 NORTHUP WAY
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98008-3045
Practice Address - Country:US
Practice Address - Phone:724-393-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-12
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE606063971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice