Provider Demographics
NPI:1487867099
Name:DR SUTINDER S KOHLI PA
Entity Type:Organization
Organization Name:DR SUTINDER S KOHLI PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUTINDER
Authorized Official - Middle Name:SINGH
Authorized Official - Last Name:KOHLI
Authorized Official - Suffix:
Authorized Official - Credentials:BDS,MS,FAGD
Authorized Official - Phone:386-255-8866
Mailing Address - Street 1:464 S RIDGEWOOD AVE
Mailing Address - Street 2:SUITE#1
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-4928
Mailing Address - Country:US
Mailing Address - Phone:386-255-8866
Mailing Address - Fax:386-872-7532
Practice Address - Street 1:464 S RIDGEWOOD AVE
Practice Address - Street 2:SUITE#1
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-4928
Practice Address - Country:US
Practice Address - Phone:386-255-8866
Practice Address - Fax:386-872-7532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN131071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty