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General NPI Number Information
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NPI Number | 1366827461
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Entity Type | Organization
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Legal Business Name | SIRIRAVALI DENTAL CARE PC
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Dates
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Enumeration Date | 07/30/2015
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Last Update Date | 07/30/2015
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Provider Practice Location Address
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Address Line | 3912 STATE HIGHWAY 30
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City | AMSTERDAM
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State | NY
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Zip | 12010-6508
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Country | US
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Telephone | 518-883-4505
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Fax | 518-883-3228
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Provider Business Mailing Address
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Address Line | 3912 STATE HIGHWAY 30
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City | AMSTERDAM
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State | NY
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Zip | 12010-6508
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Country | US
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Telephone | 518-883-4505
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Fax | 518-883-3228
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Authorized Official
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Title or Position | GENERAL DENTIST
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Name | DR. SREEDEVI MANDAVA
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Credential |
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Telephone | 518-883-4505
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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 | 043628
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License Number State | NY
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