Provider Demographics
NPI:1619656618
Name:GHOTRA, SUFUNPREET (DMD)
Entity Type:Individual
Prefix:
First Name:SUFUNPREET
Middle Name:
Last Name:GHOTRA
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 1:5528 GREENHILL PL APT J
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-7403
Mailing Address - Country:US
Mailing Address - Phone:929-519-2429
Mailing Address - Fax:
Practice Address - Street 1:8028 S EMERSON AVE STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9301
Practice Address - Country:US
Practice Address - Phone:317-648-5527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014154A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist