Healthcare Provider Details

I. General information

NPI: 1235758988
Provider Name (Legal Business Name): DIVYA SURESH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2020
Last Update Date: 04/12/2023
Certification Date: 04/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PLYMOUTH MEETING FAMILY DENTAL 350 E GERMANTOWN PIKE
EAST NORRITON PA
19401
US

IV. Provider business mailing address

415 WALLACE ST APT 2E
PHILADELPHIA PA
19123-2298
US

V. Phone/Fax

Practice location:
  • Phone: 610-828-4100
  • Fax:
Mailing address:
  • Phone: 757-375-6116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS043996
License Number StatePA
# 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: