Provider Demographics
NPI:1598851693
Name:ACHYUTA, SURYA MANGA DEVI (DDS)
Entity Type:Individual
Prefix:
First Name:SURYA MANGA
Middle Name:DEVI
Last Name:ACHYUTA
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 1:1372 N. MC DOWELL BLVD
Mailing Address - Street 2:SUITE B-1
Mailing Address - City:PETALUMA
Mailing Address - State:CA
Mailing Address - Zip Code:94954
Mailing Address - Country:US
Mailing Address - Phone:707-778-9993
Mailing Address - Fax:707-200-2146
Practice Address - Street 1:1372 N. MC DOWELL BLVD
Practice Address - Street 2:SUITE B-1
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954
Practice Address - Country:US
Practice Address - Phone:707-778-9993
Practice Address - Fax:707-200-2146
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2010-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA518891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice