Healthcare Provider Details

I. General information

NPI: 1235216185
Provider Name (Legal Business Name): SUDHEER J. SURPURE MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W UNIVERSITY AVE STE 101
FLAGSTAFF AZ
86001-3154
US

IV. Provider business mailing address

1600 W UNIVERSITY AVE STE 101
FLAGSTAFF AZ
86001-3154
US

V. Phone/Fax

Practice location:
  • Phone: 928-247-6200
  • Fax: 702-472-8575
Mailing address:
  • Phone: 928-247-6200
  • Fax: 602-957-3282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMS 89
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberOMFS SPECIALTY 157
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number41157
License Number StateAZ
# 4
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA92044
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: