Provider Demographics
NPI:1659258721
Name:DEEPTHA SURAMPUDI DDS PC
Entity type:Organization
Organization Name:DEEPTHA SURAMPUDI DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AM
Authorized Official - Prefix:
Authorized Official - First Name:PAWAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNKESULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:224-275-5215
Mailing Address - Street 1:1104 LADERA DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0044
Mailing Address - Country:US
Mailing Address - Phone:224-275-5215
Mailing Address - Fax:
Practice Address - Street 1:10106 JOHNSTON RD STE C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0141
Practice Address - Country:US
Practice Address - Phone:704-557-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-19
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty