Provider Demographics
NPI:1356467930
Name:SIRIVOLU, SURENDRA GOPAL (DDS MHA)
Entity Type:Individual
Prefix:DR
First Name:SURENDRA
Middle Name:GOPAL
Last Name:SIRIVOLU
Suffix:
Gender:M
Credentials:DDS MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1768 PARK CENTER DR
Mailing Address - Street 2:SUITE # 230
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6200
Mailing Address - Country:US
Mailing Address - Phone:407-532-0192
Mailing Address - Fax:407-532-3091
Practice Address - Street 1:1768 PARK CENTER DR
Practice Address - Street 2:SUITE # 230
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6200
Practice Address - Country:US
Practice Address - Phone:407-532-0192
Practice Address - Fax:407-532-3091
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN170571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN17057OtherDENTAL LICENSE