Provider Demographics
NPI:1346756533
Name:SUSARLA, ADVAITA (DDS)
Entity type:Individual
Prefix:
First Name:ADVAITA
Middle Name:
Last Name:SUSARLA
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 1:5621 RIVERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-6022
Mailing Address - Country:US
Mailing Address - Phone:843-641-0143
Mailing Address - Fax:
Practice Address - Street 1:5621 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-6022
Practice Address - Country:US
Practice Address - Phone:843-641-0143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-26
Last Update Date:2025-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001729122300000X
TX358961223G0001X
SC110681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist