Provider Demographics
NPI:1568031086
Name:SHIVBARAN, POORANDAI (DDS)
Entity type:Individual
Prefix:DR
First Name:POORANDAI
Middle Name:
Last Name:SHIVBARAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MRS
Other - First Name:POORANDAI
Other - Middle Name:
Other - Last Name:SANICHARRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12651 TOMBALL PKWY
Mailing Address - Street 2:STE 400
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77086
Mailing Address - Country:US
Mailing Address - Phone:305-878-9187
Mailing Address - Fax:
Practice Address - Street 1:15450 PANAMA CITY BEACH PKWY
Practice Address - Street 2:
Practice Address - City:PANAMA CITY BEACH
Practice Address - State:FL
Practice Address - Zip Code:32413-5408
Practice Address - Country:US
Practice Address - Phone:305-878-9187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-19
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX39953122300000X
FLDN259991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist