Healthcare Provider Details

I. General information

NPI: 1457091720
Provider Name (Legal Business Name): JEEVA VENKATARAMAN DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2022
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 QUINSIGAMOND AVE STE 101
WORCESTER MA
01610-1867
US

IV. Provider business mailing address

59 QUINSIGAMOND AVE STE 101
WORCESTER MA
01610-1867
US

V. Phone/Fax

Practice location:
  • Phone: 508-799-2550
  • Fax:
Mailing address:
  • Phone: 508-799-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN10001353
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: