Healthcare Provider Details

I. General information

NPI: 1669232625
Provider Name (Legal Business Name): BEENA SIVAKUMAR DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3601 HOBSON ROAD #101
FORT WAYNE IN
46815
US

IV. Provider business mailing address

3601 HOBSON ROAD #101
FORT WAYNE IN
46815
US

V. Phone/Fax

Practice location:
  • Phone: 270-243-0098
  • Fax:
Mailing address:
  • Phone: 270-243-0098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12015125A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: