Provider Demographics
NPI:1346756533
Name:SUSARLA, ADVAITA
Entity Type:Individual
Prefix:
First Name:ADVAITA
Middle Name:
Last Name:SUSARLA
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 1:2050 E ALGONQUIN RD STE 610
Mailing Address - Street 2:
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4166
Mailing Address - Country:US
Mailing Address - Phone:888-988-4066
Mailing Address - Fax:
Practice Address - Street 1:821 S LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-1225
Practice Address - Country:US
Practice Address - Phone:888-988-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2017-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001729122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist