Provider Demographics
NPI:1073578845
Name:SURESH, MYSORE S (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYSORE
Middle Name:S
Last Name:SURESH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 S CORAL KEY AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7801
Mailing Address - Country:US
Mailing Address - Phone:480-892-1123
Mailing Address - Fax:
Practice Address - Street 1:1830 S ALMA SCHOOL RD
Practice Address - Street 2:#136
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85210-3056
Practice Address - Country:US
Practice Address - Phone:480-491-0404
Practice Address - Fax:480-491-0583
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice