Provider Demographics
NPI:1376383323
Name:SURRELL, KIA-SYMONE (DMD)
Entity type:Individual
Prefix:
First Name:KIA-SYMONE
Middle Name:
Last Name:SURRELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:KIA
Other - Middle Name:SYMONE
Other - Last Name:SURRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3179 ABBEY DR SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5477
Mailing Address - Country:US
Mailing Address - Phone:510-927-7161
Mailing Address - Fax:
Practice Address - Street 1:500 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-2169
Practice Address - Country:US
Practice Address - Phone:928-289-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program