MEDICARE: AMBIKA RANI SRIVASTAVA DMD, MPH

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	D0007097-C1	AL
2	1223G0001X	General Practice Dentistry	4144-20	MS
3	1223G0001X	General Practice Dentistry	163917	AK
4	1223G0001X	General Practice Dentistry	D0007097-C1	AL

General Provider Information

NPI Number	:	1639787021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMBIKA RANI SRIVASTAVA DMD, MPH

Provider Business Mailing Address
First Line	:	1825 MCFARLAND BLVD N STE D
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2236
Country	:	US
Telephone Number	:	205-758-3341
Fax Number	:

Provider Business Practice Location Address
First Line	:	1825 MCFARLAND BLVD N STE D
Second Line	:
City	:	TUSCALOOSA
State	:	AL
Zip	:	35406-2236
Country	:	US
Telephone Number	:	205-758-3341
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2020
Last Update Date	:	05/03/2024

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