Healthcare Provider Details

I. General information

NPI: 1275670937
Provider Name (Legal Business Name): SIVAKUMAR SREENIVASAN DMD, MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 09/05/2024
Certification Date: 09/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 S WASHINGTON ST STE 205
ROCKVILLE MD
20850-2331
US

IV. Provider business mailing address

77 S WASHINGTON ST STE 205
ROCKVILLE MD
20850-2331
US

V. Phone/Fax

Practice location:
  • Phone: 301-294-8700
  • Fax: 301-294-9007
Mailing address:
  • Phone: 301-294-8700
  • Fax: 301-294-9007

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12242
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: