Provider Demographics
NPI:1518580042
Name:PANNEER SELVAM, NIRANZENA (MDS)
Entity type:Individual
Prefix:
First Name:NIRANZENA
Middle Name:
Last Name:PANNEER SELVAM
Suffix:
Gender:F
Credentials:MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5325 S111TH PLAZA APT 201
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137
Mailing Address - Country:US
Mailing Address - Phone:804-585-5189
Mailing Address - Fax:
Practice Address - Street 1:2109 CUMING STREET
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68102
Practice Address - Country:US
Practice Address - Phone:804-585-5189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1271223X0008X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0008XDental ProvidersDentistOral and Maxillofacial Radiology