Healthcare Provider Details

I. General information

NPI: 1922483890
Provider Name (Legal Business Name): AKANKSHA SRIVASTAVA BDS, MSC, MDSC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2015
Last Update Date: 01/10/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 S PAULINA ST
CHICAGO IL
60612-4353
US

IV. Provider business mailing address

811 S PAULINA ST
CHICAGO IL
60612-4353
US

V. Phone/Fax

Practice location:
  • Phone: 312-996-9158
  • Fax:
Mailing address:
  • Phone: 312-996-7546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number019.033123
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number34819
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number019033123
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: