Provider Demographics
NPI:1679933154
Name:SURPRISE FAMILY DENTISTRY
Entity type:Organization
Organization Name:SURPRISE FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHREEDEVI
Authorized Official - Middle Name:
Authorized Official - Last Name:THULASIDAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:623-556-5510
Mailing Address - Street 1:18775 N REEMS RD STE 300
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-8647
Mailing Address - Country:US
Mailing Address - Phone:623-556-5510
Mailing Address - Fax:
Practice Address - Street 1:18775 N REEMS RD STE 300
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-8647
Practice Address - Country:US
Practice Address - Phone:623-556-5510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-26
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07677122300000X, 1223G0001X, 1223P0700X
AZD05975122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty