Provider Demographics
NPI:1053833996
Name:SUDE, ASHA BALU
Entity Type:Individual
Prefix:
First Name:ASHA
Middle Name:BALU
Last Name:SUDE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1851 MACGREGOR DOWNS RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5925
Mailing Address - Country:US
Mailing Address - Phone:252-737-7000
Mailing Address - Fax:
Practice Address - Street 1:1851 MACGREGOR DOWNS RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5925
Practice Address - Country:US
Practice Address - Phone:252-737-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC002671223X2210X, 1223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodontics
No1223X2210XDental ProvidersDentistOrofacial PainGroup - Single Specialty