MEDICARE: DR. SURESH KUMAR VARMA VEGESANA D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	019028411	IL
2	122300000X	Dentist	12012081A	IN

General Provider Information

NPI Number	:	1063724805
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SURESH KUMAR VARMA VEGESANA D.D.S.

Provider Business Mailing Address
First Line	:	4512 PARNELL AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5836
Country	:	US
Telephone Number	:	260-399-1333
Fax Number	:	260-755-3271

Provider Business Practice Location Address
First Line	:	4512 PARNELL AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-5836
Country	:	US
Telephone Number	:	260-399-1333
Fax Number	:	260-755-3271

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2010
Last Update Date	:	05/17/2016

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