Healthcare Provider Details

I. General information

NPI: 1477543932
Provider Name (Legal Business Name): SUJATHA SEKAR SIVARAMAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 07/25/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2475 BROADWAY BLUFFS DR
COLUMBIA MO
65201-8148
US

IV. Provider business mailing address

1001 W WORLEY ST
COLUMBIA MO
65203-2037
US

V. Phone/Fax

Practice location:
  • Phone: 573-777-9282
  • Fax: 573-777-9569
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2005026619
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2024008518
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: