Provider Demographics
NPI:1336285030
Name:GHOSH, SUDIP
Entity Type:Individual
Prefix:DR
First Name:SUDIP
Middle Name:
Last Name:GHOSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:877 W FREMONT AVENUE, # I-2
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087
Mailing Address - Country:US
Mailing Address - Phone:408-736-7878
Mailing Address - Fax:
Practice Address - Street 1:877 W FREMONT AVE STE I2
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-2319
Practice Address - Country:US
Practice Address - Phone:408-736-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA400451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice