Provider Demographics
NPI:1356875868
Name:DR. SURENDER TIPPIREDDY DMD LLC
Entity type:Organization
Organization Name:DR. SURENDER TIPPIREDDY DMD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:SURENDER
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPPIREDDY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:614-855-5828
Mailing Address - Street 1:440 BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-1797
Mailing Address - Country:US
Mailing Address - Phone:614-855-5828
Mailing Address - Fax:614-855-5827
Practice Address - Street 1:440 BEECHER RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1797
Practice Address - Country:US
Practice Address - Phone:614-855-5828
Practice Address - Fax:614-855-5827
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300235151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0089122Medicaid