Healthcare Provider Details

I. General information

NPI: 1609505353
Provider Name (Legal Business Name): SNEHA PREM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2022
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12502 MUKILTEO SPEEDWAY STE 108
MUKILTEO WA
98275-5730
US

IV. Provider business mailing address

4 MELODY LN
LYNNFIELD MA
01940-1263
US

V. Phone/Fax

Practice location:
  • Phone: 425-374-1136
  • Fax:
Mailing address:
  • Phone: 617-359-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN100021525
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: