MEDICARE: DR. SUPRIYA SURAJ VASANTH DMD

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	1223G0001X	General Practice Dentistry	D7837	AZ
2	1223G0001X	General Practice Dentistry	DDS101865	CA

General Provider Information

NPI Number	:	1164757027
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SUPRIYA SURAJ VASANTH DMD

Provider Business Mailing Address
First Line	:	15 EL CAMINO REAL
Second Line	:
City	:	MILLBRAE
State	:	CA
Zip	:	94030-2603
Country	:	US
Telephone Number	:	650-697-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 EL CAMINO REAL
Second Line	:
City	:	MILLBRAE
State	:	CA
Zip	:	94030-2603
Country	:	US
Telephone Number	:	650-697-9000
Fax Number	:

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

Provider Enumeration Date	:	10/12/2009
Last Update Date	:	02/11/2022

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