Provider Demographics
NPI:1174626758
Name:SUDITU, ELENA C (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:ELENA
Middle Name:C
Last Name:SUDITU
Suffix:
Gender:F
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 352
Mailing Address - Street 2:7935 MAIN STREET
Mailing Address - City:HUNTER
Mailing Address - State:NY
Mailing Address - Zip Code:12442-0352
Mailing Address - Country:US
Mailing Address - Phone:518-263-4780
Mailing Address - Fax:
Practice Address - Street 1:7935 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HUNTER
Practice Address - State:NY
Practice Address - Zip Code:12442-0352
Practice Address - Country:US
Practice Address - Phone:518-263-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY031744122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist