Provider Demographics
NPI:1194436634
Name:NIVA DENTAL SPECIALISTS PLLC
Entity type:Organization
Organization Name:NIVA DENTAL SPECIALISTS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOUVIK
Authorized Official - Middle Name:
Authorized Official - Last Name:PONNUSAMY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:630-267-1199
Mailing Address - Street 1:1511 RIMSTONE DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7692
Mailing Address - Country:US
Mailing Address - Phone:630-267-1199
Mailing Address - Fax:
Practice Address - Street 1:15141 RONALD REAGAN BLVD
Practice Address - Street 2:SUITE 516
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-7864
Practice Address - Country:US
Practice Address - Phone:512-881-8852
Practice Address - Fax:512-881-7721
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-06
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty