Provider Demographics
NPI:1982829289
Name:SRISURO, SUTHANYA (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:SUTHANYA
Middle Name:
Last Name:SRISURO
Suffix:
Gender:F
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 1:1616 FRONTENAC WOODS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-3428
Mailing Address - Country:US
Mailing Address - Phone:314-569-2225
Mailing Address - Fax:
Practice Address - Street 1:3011 GODFREY RD
Practice Address - Street 2:
Practice Address - City:GODFREY
Practice Address - State:IL
Practice Address - Zip Code:62035-1808
Practice Address - Country:US
Practice Address - Phone:618-466-7966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL210008571223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1003841Medicaid
ILUNITED CONCORDIAOtherPPO NETWORK
IL227188OtherCIGNA HMO