Provider Demographics
NPI:1649806019
Name:SUBRAMANIAN, AISHWARYA
Entity type:Individual
Prefix:
First Name:AISHWARYA
Middle Name:
Last Name:SUBRAMANIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 E MORTEN AVE UNIT 2139
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4687
Mailing Address - Country:US
Mailing Address - Phone:813-728-7679
Mailing Address - Fax:
Practice Address - Street 1:22202 N CAVE CREEK RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85024-7599
Practice Address - Country:US
Practice Address - Phone:480-616-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-18
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZD011043122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program