MEDICARE: SSVA1411 LLC

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

General Provider Information

NPI Number	:	1922664267
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSVA1411 LLC

Provider Business Mailing Address
First Line	:	12576 BELLINGHAM BLVD
Second Line	:
City	:	FISHERS
State	:	IN
Zip	:	46037-4207
Country	:	US
Telephone Number	:	415-335-3537
Fax Number	:

Provider Business Practice Location Address
First Line	:	894 SIM HODGIN PKWY
Second Line	:
City	:	RICHMOND
State	:	IN
Zip	:	47374-1931
Country	:	US
Telephone Number	:	317-526-0309
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SHOBA VISWANATHAN
Credential	:	DDS
Telephone Number	:	415-335-5537

Provider Enumeration Date	:	05/13/2019
Last Update Date	:	05/13/2019

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Directions to “SSVA1411 LLC ” Practice Location

Language	Start Address	Practice Location

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