Basic Information
| Provider Information | |||||||||
| NPI: | 1578687315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | D'SILVA | ||||||||
| FirstName: | NISHA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 SOUTHWYCK BLVD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436141509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002888325 | ||||||||
| FaxNumber: | 4198665453 | ||||||||
| Practice Location | |||||||||
| Address1: | 1011 N UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481091078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347636933 | ||||||||
| FaxNumber: | 7347642469 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2007 | ||||||||
| LastUpdateDate: | 01/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2901017792 | MI | N | Dental Providers | Dentist | 207ZP0102X | 2901017792 | MI | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 1223P0106X | 2901017792 | MI | Y | Dental Providers | Dentist | Oral and Maxillofacial Pathology |
ID Information
| ID | Type | State | Issuer | Description | 19009265 | 01 | MI | MEDICARE RAILROAD | OTHER | D017792 | 01 | MI | BCBS OF MI DENTAL | OTHER | 1958162970 | 01 | MI | BCBS OF MI MED SURGICAL | OTHER | 4165789 | 05 | MI | MEDICAID | 4873706 | 05 | MI | MEDICAID |