Provider Demographics
NPI:1760821037
Name:BATHINA, SUMAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUMAN
Middle Name:
Last Name:BATHINA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 DAVIS LN APT 922
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78749-4564
Mailing Address - Country:US
Mailing Address - Phone:310-997-6558
Mailing Address - Fax:
Practice Address - Street 1:2400 E OLTORF ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78741-4563
Practice Address - Country:US
Practice Address - Phone:512-822-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-20
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX29137122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist