Healthcare Provider Details

I. General information

NPI: 1447221627
Provider Name (Legal Business Name): SUJATHA H DE SILVA DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 08/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 PIKE STREET
PORT JERVIS NY
12771
US

IV. Provider business mailing address

141 PIKE STREET
PORT JERVIS NY
12771
US

V. Phone/Fax

Practice location:
  • Phone: 845-856-4002
  • Fax: 845-856-4002
Mailing address:
  • Phone: 845-856-4002
  • Fax: 845-856-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SUJATHA H DE SILVA
Title or Position: PRINCIPAL
Credential: DDS
Phone: 845-856-4002