Provider Demographics
NPI:1679913636
Name:SRIVASTAVA, SUMEET KUMAR (DDS)
Entity type:Individual
Prefix:DR
First Name:SUMEET
Middle Name:KUMAR
Last Name:SRIVASTAVA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25771 TERRA BELLA AVE
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-5637
Mailing Address - Country:US
Mailing Address - Phone:510-543-4936
Mailing Address - Fax:
Practice Address - Street 1:12791 NEWPORT AVE
Practice Address - Street 2:SUITE #200
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2751
Practice Address - Country:US
Practice Address - Phone:714-730-7777
Practice Address - Fax:714-730-7797
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-04
Last Update Date:2013-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist