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General NPI Number Information
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NPI Number | 1497210546
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Entity Type | Organization
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Legal Business Name | SPRINGFIELD PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 02/04/2019
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Last Update Date | 02/04/2019
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Provider Practice Location Address
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Address Line | 1224 CENTRE WEST DR
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City | SPRINGFIELD
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State | IL
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Zip | 62704-2184
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Country | US
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Telephone | 217-666-0098
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Fax |
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Provider Business Mailing Address
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Address Line | 10900 FOX CRST
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City | SAN ANTONIO
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State | TX
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Zip | 78233-7249
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Country | US
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Telephone | 217-666-0098
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Fax |
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Authorized Official
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Title or Position | DENTIST/PRESIDENT
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Name | DR. SIRISHA GOVINDAIAH
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Credential | BDS, MPH, DDS
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Telephone | 217-666-0098
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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