Healthcare Provider Details

I. General information

NPI: 1497210546
Provider Name (Legal Business Name): SPRINGFIELD PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2019
Last Update Date: 02/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1224 CENTRE WEST DR
SPRINGFIELD IL
62704-2184
US

IV. Provider business mailing address

10900 FOX CRST
SAN ANTONIO TX
78233-7249
US

V. Phone/Fax

Practice location:
  • Phone: 217-666-0098
  • Fax:
Mailing address:
  • Phone: 217-666-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. SIRISHA GOVINDAIAH
Title or Position: DENTIST/PRESIDENT
Credential: BDS, MPH, DDS
Phone: 217-666-0098