Healthcare Provider Details

I. General information

NPI: 1194341347
Provider Name (Legal Business Name): SRIVIDYA PUTCHHA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 08/01/2020
Certification Date: 08/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 WHITAKER ST
HOMESTEAD PA
15120-2411
US

IV. Provider business mailing address

2700 SUNSET BLVD
STEUBENVILLE OH
43952-1158
US

V. Phone/Fax

Practice location:
  • Phone: 740-485-0309
  • Fax:
Mailing address:
  • Phone: 740-314-4941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.026266
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: