Healthcare Provider Details

I. General information

NPI: 1972429116
Provider Name (Legal Business Name): SHRUTI SIVAKUMAR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

IV. Provider business mailing address

16859 YELLOWSTONE DR
NORTHVILLE MI
48168-6846
US

V. Phone/Fax

Practice location:
  • Phone: 309-655-2000
  • Fax:
Mailing address:
  • Phone: 248-719-8509
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019.037230
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: