Provider Demographics
NPI:1972280543
Name:PREMARAJ, SHYAMALY (DDS)
Entity type:Individual
Prefix:DR
First Name:SHYAMALY
Middle Name:
Last Name:PREMARAJ
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 1:3611 SW 34TH ST APT 62
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-2581
Mailing Address - Country:US
Mailing Address - Phone:402-802-7333
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-3006
Practice Address - Country:US
Practice Address - Phone:352-273-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDRPM2605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist