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General NPI Number Information
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NPI Number | 1477917706
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Entity Type | Organization
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Legal Business Name | SAI ORAL SURGERY
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Dates
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Enumeration Date | 04/13/2016
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Last Update Date | 04/13/2016
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Provider Practice Location Address
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Address Line | 1728 DUNLAWTON AVE SUITE 3
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City | PORT ORANGE
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State | FL
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Zip | 32127-2922
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Country | US
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Telephone | 412-913-8877
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Fax |
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Provider Business Mailing Address
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Address Line | 1728 DUNLAWTON AVE SUITE 3
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City | PORT ORANGE
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State | FL
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Zip | 32127-2922
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Country | US
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Telephone | 412-913-8877
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | SRAVANTHI GANNE
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Credential | DDS MD
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Telephone | 412-913-8877
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QS0112X
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Taxonomy Name | Oral and Maxillofacial Surgery Clinic/Center
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License Number | DN19304
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License Number State | FL
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