Provider Demographics
NPI:1578637823
Name:SUNDARAM, SURESH (DDS)
Entity Type:Individual
Prefix:DR
First Name:SURESH
Middle Name:
Last Name:SUNDARAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SARATOGA VILLAGE BLVD
Mailing Address - Street 2:SUITE 36A
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3737
Mailing Address - Country:US
Mailing Address - Phone:518-899-9783
Mailing Address - Fax:518-899-4007
Practice Address - Street 1:4 NORMANSKILL BLVD
Practice Address - Street 2:
Practice Address - City:DELMAR
Practice Address - State:NY
Practice Address - Zip Code:12054-1335
Practice Address - Country:US
Practice Address - Phone:518-475-7822
Practice Address - Fax:518-439-0530
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY049151-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02625336Medicaid