Provider Demographics
NPI:1104001015
Name:SURYAMANGA.D.ACHYUTA,DDS,INC
Entity Type:Organization
Organization Name:SURYAMANGA.D.ACHYUTA,DDS,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SURYAMANGA
Authorized Official - Middle Name:D
Authorized Official - Last Name:ACHYUTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-778-9993
Mailing Address - Street 1:1372 N MCDOWELL BLVD
Mailing Address - Street 2:SUITE#B-1
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954-1179
Mailing Address - Country:US
Mailing Address - Phone:707-778-9993
Mailing Address - Fax:
Practice Address - Street 1:1372 N MCDOWELL BLVD
Practice Address - Street 2:SUITE#B-1
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-1179
Practice Address - Country:US
Practice Address - Phone:707-778-9993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA518891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty