MEDICARE: LINDA R SURALIE DDS

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	1223P0300X	Periodontics	DS029075-L	PA

General Provider Information

NPI Number	:	1629292529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA R SURALIE DDS

Provider Business Mailing Address
First Line	:	7715 CRITTENDEN ST
Second Line	:	#336
City	:	PHILA
State	:	PA
Zip	:	19118-4421
Country	:	US
Telephone Number	:	215-242-3397
Fax Number	:	215-242-1171

Provider Business Practice Location Address
First Line	:	7156 STENTON AVE
Second Line	:
City	:	PHILA
State	:	PA
Zip	:	19150-3428
Country	:	US
Telephone Number	:	215-242-3397
Fax Number	:	215-242-1171

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

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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