Provider Demographics
NPI:1053011783
Name:PRAKASH, SRIVIDYA (DMD, BDS)
Entity type:Individual
Prefix:
First Name:SRIVIDYA
Middle Name:
Last Name:PRAKASH
Suffix:
Gender:F
Credentials:DMD, BDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 DEER ST APT 2418
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01757-5155
Mailing Address - Country:US
Mailing Address - Phone:978-955-1448
Mailing Address - Fax:
Practice Address - Street 1:297 UNION AVE
Practice Address - Street 2:
Practice Address - City:FRAMINGHAM
Practice Address - State:MA
Practice Address - Zip Code:01702-6378
Practice Address - Country:US
Practice Address - Phone:508-709-9268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1860026122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist