1710067095 NPI number — DR. PRASANNA KUMAR SHIVAPUJA BDS,MDS,DDS,MS ORTHO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710067095 NPI number — DR. PRASANNA KUMAR SHIVAPUJA BDS,MDS,DDS,MS ORTHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHIVAPUJA
Provider First Name:
PRASANNA
Provider Middle Name:
KUMAR
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
BDS,MDS,DDS,MS ORTHO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710067095
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25979 KELLY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48066-4941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
586-779-3440
Provider Business Mailing Address Fax Number:
586-779-0091

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25979 KELLY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48066-4941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
586-779-3440
Provider Business Practice Location Address Fax Number:
586-779-0091
Provider Enumeration Date:
10/17/2006

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: 1223X0400X , with the licence number:  14629 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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