Provider Demographics
NPI:1306839386
Name:SURIS, JOSE ANTONIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:ANTONIO
Last Name:SURIS
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:PO BOX 45082
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92145-0082
Mailing Address - Country:US
Mailing Address - Phone:858-437-2581
Mailing Address - Fax:
Practice Address - Street 1:BRANCH DENTAL CLINIC MCAS MIRAMAR
Practice Address - Street 2:BUILDING 2495
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145
Practice Address - Country:US
Practice Address - Phone:858-577-1825
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR26031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice