Healthcare Provider Details

I. General information

NPI: 1942797550
Provider Name (Legal Business Name): SRUTHI SATISHCHANDRAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E PONCE DE LEON AVE STE 250
DECATUR GA
30030-3472
US

IV. Provider business mailing address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

V. Phone/Fax

Practice location:
  • Phone: 770-589-1440
  • Fax: 770-800-7823
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDN122574
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: