1598936676 NPI number — DR. SOUMYA SHIVANNA DDS

Table of content: DR. SOUMYA SHIVANNA DDS (NPI 1598936676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598936676 NPI number — DR. SOUMYA SHIVANNA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIVANNA
Provider First Name:
SOUMYA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHIVANNA
Provider Other First Name:
SOUMYA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1598936676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 E. CAPITOL EXPRESSWAY, SUITE C
Provider Second Line Business Mailing Address:
EVERGREEN FAMILY DENTAL GROUP
Provider Business Mailing Address City Name:
SAN JOSE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
408-223-6017
Provider Business Mailing Address Fax Number:
408-223-6019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 E.CAPITOL EXPRESSWAY
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
SAN JOSE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-223-6017
Provider Business Practice Location Address Fax Number:
408-223-6019
Provider Enumeration Date:
03/18/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  55657 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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