Healthcare Provider Details

I. General information

NPI: 1538303144
Provider Name (Legal Business Name): SRINIVASA RAMA CHANDRA MD, DDS, FDSRCS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 10/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 9TH AVE 4 WEST CLINIC, BOX-359893,
SEATTLE WA
98104-2420
US

IV. Provider business mailing address

325 9TH AVE 4 WEST CLINIC, BOX-359893,
SEATTLE WA
98104-2420
US

V. Phone/Fax

Practice location:
  • Phone: 206-744-3224
  • Fax: 206-744-2810
Mailing address:
  • Phone: 206-744-3224
  • Fax: 206-744-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number60478567
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number60478567
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: