Provider Demographics
NPI:1356909352
Name:TRIVEDI, SUJAY (DMD)
Entity type:Individual
Prefix:DR
First Name:SUJAY
Middle Name:
Last Name:TRIVEDI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5950 PALM TRACE LANDINGS DR APT 306
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-1818
Mailing Address - Country:US
Mailing Address - Phone:860-805-8875
Mailing Address - Fax:
Practice Address - Street 1:10156 INDIANTOWN RD
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33478-4707
Practice Address - Country:US
Practice Address - Phone:561-743-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-04
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN241551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN24155OtherFLORIDA BOARD OF DENTISTRY