=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952074841
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIYATHI SRINIVASAN DMD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2021
-----------------------------------------------------
Last Update Date | 12/01/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 WILLOWBROOK LN STE 300
-----------------------------------------------------
City | WEST CHESTER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19382-5594
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-470-4833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1547 WILLIAMS RD
-----------------------------------------------------
City | ABINGTON
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19001-1908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-470-4833
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | DS043156
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------