Healthcare Provider Details

I. General information

NPI: 1881949592
Provider Name (Legal Business Name): AISHWARYA INDIRAMOHAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 N 9TH ST
SPRINGFIELD IL
62702-6309
US

IV. Provider business mailing address

5700 EDWARDS RANCH RD STE 100
FORT WORTH TX
76109-4128
US

V. Phone/Fax

Practice location:
  • Phone: 888-988-4066
  • Fax: 847-496-7603
Mailing address:
  • Phone: 817-292-2004
  • Fax: 178-292-7083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.029137
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number31773
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: