Healthcare Provider Details

I. General information

NPI: 1437185766
Provider Name (Legal Business Name): AJAY SURI DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 09/19/2023
Certification Date: 09/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 RAHLING CIR
LITTLE ROCK AR
72223-9191
US

IV. Provider business mailing address

PO BOX 241534
LITTLE ROCK AR
72223-0010
US

V. Phone/Fax

Practice location:
  • Phone: 501-821-5859
  • Fax: 501-588-3455
Mailing address:
  • Phone: 501-821-5859
  • Fax: 501-588-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3513 / 109
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number20901
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7493
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: