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General NPI Number Information
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NPI Number | 1679933154
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Entity Type | Organization
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Legal Business Name | SURPRISE FAMILY DENTISTRY
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Dates
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Enumeration Date | 02/26/2016
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Last Update Date | 11/01/2016
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Provider Practice Location Address
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Address Line | 18775 N REEMS RD STE 300
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City | SURPRISE
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State | AZ
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Zip | 85374-8647
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Country | US
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Telephone | 623-556-5510
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Fax |
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Provider Business Mailing Address
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Address Line | 18775 N REEMS RD STE 300
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City | SURPRISE
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State | AZ
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Zip | 85374-8647
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Country | US
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Telephone | 623-556-5510
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SHREEDEVI THULASIDAS
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Credential | DDS MS
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Telephone | 623-556-5510
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D07677
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D07677
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License Number State | AZ
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D05975
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License Number State | AZ
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Taxonomy #4
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | D07677
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License Number State | AZ
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D05975
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License Number State | AZ
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