Provider Demographics
NPI:1316924954
Name:THEVANAYAGAM, VASUKI (DDS)
Entity type:Individual
Prefix:DR
First Name:VASUKI
Middle Name:
Last Name:THEVANAYAGAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 KING ANTHONY WAY
Mailing Address - Street 2:
Mailing Address - City:GETZVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14068-1415
Mailing Address - Country:US
Mailing Address - Phone:716-568-1163
Mailing Address - Fax:716-568-1163
Practice Address - Street 1:2878 NIAGARA FALLS BLVD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:NY
Practice Address - Zip Code:14228-2020
Practice Address - Country:US
Practice Address - Phone:716-693-2861
Practice Address - Fax:716-693-7028
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0490371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02122003Medicaid
NY0015696OtherDORAL