MEDICARE: APARNA SRINIVASA 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	1223G0001X	General Practice Dentistry	019.028604	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	019.028604	OTHER	IL	LICENSE

General Provider Information

NPI Number	:	1922394006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	APARNA SRINIVASA DDS

Provider Business Mailing Address
First Line	:	2563 SYCAMORE RD
Second Line	:
City	:	DEKALB
State	:	IL
Zip	:	60115-2051
Country	:	US
Telephone Number	:	815-748-2666
Fax Number	:	815-748-3981

Provider Business Practice Location Address
First Line	:	2563 SYCAMORE RD
Second Line	:
City	:	DEKALB
State	:	IL
Zip	:	60115-2051
Country	:	US
Telephone Number	:	815-748-2666
Fax Number	:	815-748-3981

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

Provider Enumeration Date	:	06/27/2011
Last Update Date	:	06/27/2011

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