Healthcare Provider Details

I. General information

NPI: 1114583325
Provider Name (Legal Business Name): DIPAK SURI DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2019
Last Update Date: 07/13/2021
Certification Date: 07/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 CHANNING WAY
BERKELEY CA
94704-2123
US

IV. Provider business mailing address

939 DEWING AVE
LAFAYETTE CA
94549-4251
US

V. Phone/Fax

Practice location:
  • Phone: 510-845-6494
  • Fax:
Mailing address:
  • Phone: 925-997-5104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number103094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: