Provider Demographics
NPI:1083683643
Name:SUDA, DIANE A (DMD)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:A
Last Name:SUDA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 SPRINGS RD
Mailing Address - Street 2:BEDFORD VETERANS AFFAIRS MEDICAL CENTER, DENTAL
Mailing Address - City:BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01730-1114
Mailing Address - Country:US
Mailing Address - Phone:781-687-2000
Mailing Address - Fax:
Practice Address - Street 1:200 SPRINGS RD
Practice Address - Street 2:BEDFORD VETERANS AFFAIRS MEDICAL CENTER, DENTAL
Practice Address - City:BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:01730-1114
Practice Address - Country:US
Practice Address - Phone:781-687-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2015-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA156531223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPH148OtherHARVARD PILGRIM
MAV06040OtherBCBS - DENTAL