Provider Demographics
NPI:1598936676
Name:SHIVANNA, SOUMYA (DDS)
Entity type:Individual
Prefix:DR
First Name:SOUMYA
Middle Name:
Last Name:SHIVANNA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:SOUMYA
Other - Middle Name:
Other - Last Name:SHIVANNA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1620 E. CAPITOL EXPRESSWAY, SUITE C
Mailing Address - Street 2:EVERGREEN FAMILY DENTAL GROUP
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95121
Mailing Address - Country:US
Mailing Address - Phone:408-223-6017
Mailing Address - Fax:408-223-6019
Practice Address - Street 1:1620 E.CAPITOL EXPRESSWAY
Practice Address - Street 2:SUITE C
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121
Practice Address - Country:US
Practice Address - Phone:408-223-6017
Practice Address - Fax:408-223-6019
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-18
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA556571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice