MEDICARE: DR. MYSORE S SURESH D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	3857	AZ

General Provider Information

NPI Number	:	1073578845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MYSORE S SURESH D.D.S

Provider Business Mailing Address
First Line	:	1113 S CORAL KEY AVE
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-7801
Country	:	US
Telephone Number	:	480-892-1123
Fax Number	:

Provider Business Practice Location Address
First Line	:	1830 S ALMA SCHOOL RD
Second Line	:	#136
City	:	MESA
State	:	AZ
Zip	:	85210-3056
Country	:	US
Telephone Number	:	480-491-0404
Fax Number	:	480-491-0583

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2006
Last Update Date	:	07/08/2007

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