MEDICARE: SVK DENTAL PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DN22184	MA

General Provider Information

NPI Number	:	1477926566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SVK DENTAL PC

Provider Business Mailing Address
First Line	:	1401 ROCK WOOD DR
Second Line	:
City	:	SAUGUS
State	:	MA
Zip	:	01906-4537
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1225 LIBERTY ST
Second Line	:	UNIT 3
City	:	SPRINGFIELD
State	:	MA
Zip	:	01104-1165
Country	:	US
Telephone Number	:	413-788-0000
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SRINIVAS DESANEEDI
Credential	:	DMD
Telephone Number	:	740-215-8549

Provider Enumeration Date	:	11/11/2015
Last Update Date	:	11/11/2015

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