Healthcare Provider Details

I. General information

NPI: 1194213314
Provider Name (Legal Business Name): SURYA CHAKRAVARTHY PAMULAPATI BDS, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2018
Last Update Date: 01/28/2022
Certification Date: 01/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6016 GLENWAY AVE
CINCINNATI OH
45211-6318
US

IV. Provider business mailing address

6476 TYLERSVILLE RD
WEST CHESTER OH
45069-5412
US

V. Phone/Fax

Practice location:
  • Phone: 513-697-2640
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30.026329
License Number StateOH
# 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: