Provider Demographics
NPI:1518117589
Name:SUNDARESAN, SULAKSHANA (DDS)
Entity Type:Individual
Prefix:MRS
First Name:SULAKSHANA
Middle Name:
Last Name:SUNDARESAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CHURCH STREET
Mailing Address - Street 2:
Mailing Address - City:YALESVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06492
Mailing Address - Country:US
Mailing Address - Phone:203-774-0019
Mailing Address - Fax:203-774-0034
Practice Address - Street 1:60 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:YALESVILLE
Practice Address - State:CT
Practice Address - Zip Code:06492
Practice Address - Country:US
Practice Address - Phone:203-774-0019
Practice Address - Fax:203-774-0034
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT96561223D0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTMCD008001178Medicaid