Provider Demographics
NPI:1235216185
Name:SURPURE, SUDHEER J (MD, DDS)
Entity Type:Individual
Prefix:
First Name:SUDHEER
Middle Name:J
Last Name:SURPURE
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W UNIVERSITY AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3154
Mailing Address - Country:US
Mailing Address - Phone:928-247-6200
Mailing Address - Fax:602-957-3282
Practice Address - Street 1:1600 W UNIVERSITY AVE STE 101
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-3154
Practice Address - Country:US
Practice Address - Phone:928-247-6200
Practice Address - Fax:702-472-8575
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOMS 891223S0112X
OKOMFS SPECIALTY 1571223S0112X
AZ41157204E00000X
CAA92044204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A920440Medicaid
CA00A920440Medicaid
00A920440Medicare ID - Type Unspecified