Provider Demographics
NPI:1477561264
Name:SUNNYVALE DENTIST
Entity Type:Organization
Organization Name:SUNNYVALE DENTIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LALITHA
Authorized Official - Middle Name:N
Authorized Official - Last Name:KOTHURI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-524-5505
Mailing Address - Street 1:877 W FREMONT AVE
Mailing Address - Street 2:SUITE A-2
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087
Mailing Address - Country:US
Mailing Address - Phone:408-524-5505
Mailing Address - Fax:408-524-5506
Practice Address - Street 1:877 W FREMONT AVE
Practice Address - Street 2:SUITE A-2
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087
Practice Address - Country:US
Practice Address - Phone:408-524-5505
Practice Address - Fax:408-524-5506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty