Provider Demographics
NPI:1508410580
Name:VANMALI, SURAJ (DMD)
Entity Type:Individual
Prefix:
First Name:SURAJ
Middle Name:
Last Name:VANMALI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 CHEROKEE BLVD
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30134-2535
Mailing Address - Country:US
Mailing Address - Phone:678-557-3463
Mailing Address - Fax:
Practice Address - Street 1:2285 PEACHTREE RD NE STE 203
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-1121
Practice Address - Country:US
Practice Address - Phone:404-842-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC94641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice