Provider Demographics
NPI:1922095181
Name:THIKKURISSY, SARAT (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SARAT
Middle Name:
Last Name:THIKKURISSY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 BURNET AVE
Mailing Address - Street 2:DENTISTRY ML 2006
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3026
Mailing Address - Country:US
Mailing Address - Phone:513-636-4641
Mailing Address - Fax:513-636-8283
Practice Address - Street 1:3333 BURNET AVE
Practice Address - Street 2:DENTISTRY ML 2006
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45229-3026
Practice Address - Country:US
Practice Address - Phone:513-636-4641
Practice Address - Fax:513-636-8283
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0209961223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2647667Medicaid
KY7100252000Medicaid
IN201218320Medicaid
WV3810026591Medicaid