Provider Demographics
NPI:1366827461
Name:SIRIRAVALI DENTAL CARE PC
Entity type:Organization
Organization Name:SIRIRAVALI DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SREEDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDAVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-883-4505
Mailing Address - Street 1:3912 STATE HIGHWAY 30
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-6508
Mailing Address - Country:US
Mailing Address - Phone:518-883-4505
Mailing Address - Fax:518-883-3228
Practice Address - Street 1:3912 STATE HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010-6508
Practice Address - Country:US
Practice Address - Phone:518-883-4505
Practice Address - Fax:518-883-3228
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIRIRAVALI DENTAL CARE PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty