Healthcare Provider Details

I. General information

NPI: 1922154301
Provider Name (Legal Business Name): SURESH K NAIDU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 DUDLEY ST
ROXBURY MA
02119
US

IV. Provider business mailing address

156 DUDLEY ST
ROXBURY MA
02119
US

V. Phone/Fax

Practice location:
  • Phone: 617-445-7050
  • Fax: 617-445-7051
Mailing address:
  • Phone: 617-445-7050
  • Fax: 617-445-7051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13632
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: