Provider Demographics
NPI:1063177566
Name:DENTIST IN PALM BEACH GARDENS
Entity type:Organization
Organization Name:DENTIST IN PALM BEACH GARDENS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:SIRIVOLU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:561-707-2594
Mailing Address - Street 1:11903 SOUTHERN BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:ROYAL PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33411-7644
Mailing Address - Country:US
Mailing Address - Phone:561-795-7668
Mailing Address - Fax:561-795-7884
Practice Address - Street 1:3385 BURNS RD STE 206
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4328
Practice Address - Country:US
Practice Address - Phone:561-795-7668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty