MEDICARE: DR. VISHALAKSHI SRIRAM DDS

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	61517	CA

General Provider Information

NPI Number	:	1700132305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. VISHALAKSHI SRIRAM DDS

Provider Business Mailing Address
First Line	:	1124 PIERCE DR APT 1
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-1543
Country	:	US
Telephone Number	:	559-321-3221
Fax Number	:

Provider Business Practice Location Address
First Line	:	1124 PIERCE DR APT 1
Second Line	:
City	:	CLOVIS
State	:	CA
Zip	:	93612-1543
Country	:	US
Telephone Number	:	559-321-3221
Fax Number	:

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

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	08/01/2012

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