Healthcare Provider Details

I. General information

NPI: 1720522154
Provider Name (Legal Business Name): SHIVA SEYYADRI BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2016
Last Update Date: 03/21/2022
Certification Date: 03/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E DALKE AVE
SPOKANE WA
99208-8112
US

IV. Provider business mailing address

611 N IRON BRIDGE WAY
SPOKANE WA
99202-4932
US

V. Phone/Fax

Practice location:
  • Phone: 509-444-8200
  • Fax:
Mailing address:
  • Phone: 509-444-8888
  • Fax: 509-444-7806

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDE60665197
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: