Provider Demographics
NPI:1780695130
Name:REVUR, SUJATHA L (GENERAL DENTISTRY)
Entity type:Individual
Prefix:
First Name:SUJATHA
Middle Name:L
Last Name:REVUR
Suffix:
Gender:F
Credentials:GENERAL DENTISTRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 QUEEN ST
Mailing Address - Street 2:DENTAL
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01610-2473
Mailing Address - Country:US
Mailing Address - Phone:508-860-7700
Mailing Address - Fax:508-860-7990
Practice Address - Street 1:26 QUEEN ST
Practice Address - Street 2:DENTAL
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01610-2473
Practice Address - Country:US
Practice Address - Phone:508-860-7700
Practice Address - Fax:508-860-7990
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19824122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300709Medicaid
MA41770OtherHARVARD PILGRIM
MA19824OtherALTUS DENTAL
MA19824OtherAMERITAS
MAY10141OtherBCBS DENTAL-GROUP
MA19824OtherBCBS DENTAL
MA19824OtherANTHEM BCBS DENTAL
MA19824OtherANTHEM BLUECARE
MA19824OtherGUARDIAN DENTAL
MA41770OtherHARVARD PILGRIM