MEDICARE: SURAJ VANMALI DMD

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	9464	SC

General Provider Information

NPI Number	:	1508410580
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SURAJ VANMALI DMD

Provider Business Mailing Address
First Line	:	8304 CHEROKEE BLVD
Second Line	:
City	:	DOUGLASVILLE
State	:	GA
Zip	:	30134-2535
Country	:	US
Telephone Number	:	678-557-3463
Fax Number	:

Provider Business Practice Location Address
First Line	:	2285 PEACHTREE RD NE STE 203
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30309-1121
Country	:	US
Telephone Number	:	404-842-7200
Fax Number	:

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

Provider Enumeration Date	:	07/29/2019
Last Update Date	:	02/03/2021

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