Provider Demographics
NPI:1124228713
Name:NELATOOR, SUGANYA
Entity Type:Individual
Prefix:
First Name:SUGANYA
Middle Name:
Last Name:NELATOOR
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 1:102 WAXHAW PROFESSIONAL PARK DR STE E
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-5025
Mailing Address - Country:US
Mailing Address - Phone:704-256-3548
Mailing Address - Fax:704-256-3548
Practice Address - Street 1:102 WAXHAW PROFESSIONAL PARK DR STE E
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5025
Practice Address - Country:US
Practice Address - Phone:704-256-3548
Practice Address - Fax:704-256-3548
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC096191223G0001X
DCDEN10004391223G0001X
VA04014110011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice