Provider Demographics
NPI:1205821915
Name:MITTAL, SURESH C (DDS)
Entity Type:Individual
Prefix:
First Name:SURESH
Middle Name:C
Last Name:MITTAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3108
Mailing Address - Country:US
Mailing Address - Phone:718-783-1646
Mailing Address - Fax:718-783-1646
Practice Address - Street 1:153 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-3108
Practice Address - Country:US
Practice Address - Phone:718-783-1646
Practice Address - Fax:718-783-1646
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY033444122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00297732Medicaid