MEDICARE: SHIYAMALI SUNDARARAJAN

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	1223P0300X	Periodontics	39852	TX

General Provider Information

NPI Number	:	1679254544
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHIYAMALI SUNDARARAJAN

Provider Business Mailing Address
First Line	:	529 CADDO LAKE DR
Second Line	:
City	:	GEORGETOWN
State	:	TX
Zip	:	78628-7137
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12319 N MOPAC EXPY STE 160
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78758-2648
Country	:	US
Telephone Number	:	512-222-5721
Fax Number	:

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

Provider Enumeration Date	:	07/25/2023
Last Update Date	:	07/25/2023

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