Provider Demographics
NPI:1699930867
Name:SANAM, VIJITHA (DMD)
Entity type:Individual
Prefix:
First Name:VIJITHA
Middle Name:
Last Name:SANAM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:274 WALNUT ST
Mailing Address - Street 2:UNIT-1
Mailing Address - City:SHREWSBURY
Mailing Address - State:MA
Mailing Address - Zip Code:01545-3318
Mailing Address - Country:US
Mailing Address - Phone:508-925-5562
Mailing Address - Fax:
Practice Address - Street 1:274 WALNUT ST
Practice Address - Street 2:UNIT-1
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3318
Practice Address - Country:US
Practice Address - Phone:508-925-5562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-27
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA22154122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA22154OtherDENTAL LICENSE