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General NPI Number Information
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NPI Number | 1326418518
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Entity Type | Individual
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Provider Name | DEEPASULOCHANA SIVASANKARAGANESAN D.M.D
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Gender | Female
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Dates
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Enumeration Date | 09/30/2015
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Last Update Date | 12/26/2018
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Provider Practice Location Address
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Address Line | 3719 JEWELLA AVE
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City | SHREVEPORT
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State | LA
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Zip | 71109
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Country | US
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Telephone | 318-550-3362
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Fax |
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Provider Business Mailing Address
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Address Line | 3719 JEWELLA AVE
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City | SHREVEPORT
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State | LA
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Zip | 71109-4703
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Country | US
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Telephone | 330-840-9341
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN1857088
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 6936
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License Number State | LA
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