Provider Demographics
NPI:1972028488
Name:SIVARAMAN, SUDARVIZHI (DMD)
Entity type:Individual
Prefix:DR
First Name:SUDARVIZHI
Middle Name:
Last Name:SIVARAMAN
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 1:21219 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1045
Mailing Address - Country:US
Mailing Address - Phone:313-882-7961
Mailing Address - Fax:
Practice Address - Street 1:21219 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1045
Practice Address - Country:US
Practice Address - Phone:313-882-7961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-04
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010224651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice