Provider Demographics
NPI:1578999462
Name:UNIVERSAL SMILES DENTISTRY PA
Entity Type:Organization
Organization Name:UNIVERSAL SMILES DENTISTRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:SURENDRA
Authorized Official - Middle Name:G
Authorized Official - Last Name:SIRIVOLU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:321-278-3933
Mailing Address - Street 1:6735 CONROY WINDERMERE RD
Mailing Address - Street 2:SUITE# 202
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-3565
Mailing Address - Country:US
Mailing Address - Phone:407-910-1178
Mailing Address - Fax:
Practice Address - Street 1:6735 CONROY WINDERMERE RD
Practice Address - Street 2:SUITE# 202
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-3565
Practice Address - Country:US
Practice Address - Phone:407-910-1178
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN17057261QD0000X
FLDN17923261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental