Provider Demographics
NPI:1316225683
Name:IRAGAVARAPU, SRINIVAS (DMD)
Entity type:Individual
Prefix:
First Name:SRINIVAS
Middle Name:
Last Name:IRAGAVARAPU
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12203-2711
Mailing Address - Country:US
Mailing Address - Phone:617-869-7411
Mailing Address - Fax:
Practice Address - Street 1:1021 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-2711
Practice Address - Country:US
Practice Address - Phone:518-482-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-03
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY055498122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist