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General NPI Number Information
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NPI Number | 1508410580
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Entity Type | Individual
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Provider Name | SURAJ VANMALI DMD
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Gender | Male
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Dates
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Enumeration Date | 07/29/2019
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Last Update Date | 02/03/2021
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Provider Practice Location Address
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Address Line | 2285 PEACHTREE RD NE STE 203
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City | ATLANTA
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State | GA
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Zip | 30309-1121
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Country | US
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Telephone | 404-842-7200
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Fax |
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Provider Business Mailing Address
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Address Line | 8304 CHEROKEE BLVD
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City | DOUGLASVILLE
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State | GA
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Zip | 30134-2535
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Country | US
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Telephone | 678-557-3463
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 9464
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License Number State | SC
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