Provider Demographics
NPI:1992208276
Name:PANCHOLI, SURABHI (DDS)
Entity Type:Individual
Prefix:
First Name:SURABHI
Middle Name:
Last Name:PANCHOLI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 1ST AVE NE UNIT 961
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-3171
Mailing Address - Country:US
Mailing Address - Phone:614-634-3521
Mailing Address - Fax:
Practice Address - Street 1:2500 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1460
Practice Address - Country:US
Practice Address - Phone:651-647-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-13
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013100A122300000X
KY10397122300000X
MND14504122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist