Provider Demographics
NPI:1164757027
Name:VASANTH, SUPRIYA SURAJ (DMD)
Entity Type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:SURAJ
Last Name:VASANTH
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 1:15 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2603
Mailing Address - Country:US
Mailing Address - Phone:650-697-9000
Mailing Address - Fax:
Practice Address - Street 1:15 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MILLBRAE
Practice Address - State:CA
Practice Address - Zip Code:94030-2603
Practice Address - Country:US
Practice Address - Phone:650-697-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD78371223G0001X
CADDS1018651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice