Provider Demographics
NPI:1609178847
Name:SURYANARAYANAN, DEEPA (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEEPA
Middle Name:
Last Name:SURYANARAYANAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 15TH ST S APT 1004
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22202-5020
Mailing Address - Country:US
Mailing Address - Phone:571-265-3969
Mailing Address - Fax:
Practice Address - Street 1:10905 FORT WASHINGTON RD
Practice Address - Street 2:207
Practice Address - City:FORT WASHINGTON
Practice Address - State:MD
Practice Address - Zip Code:20744-5843
Practice Address - Country:US
Practice Address - Phone:301-292-6807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-20
Last Update Date:2011-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD14792122300000X
VA04014130271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist