Provider Demographics
NPI:1043895154
Name:SURDI, PATRICE
Entity type:Individual
Prefix:
First Name:PATRICE
Middle Name:
Last Name:SURDI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 E 58TH ST APT 3B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-2337
Mailing Address - Country:US
Mailing Address - Phone:425-343-9016
Mailing Address - Fax:
Practice Address - Street 1:57 W 57TH ST STE 1104
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-2814
Practice Address - Country:US
Practice Address - Phone:212-421-4887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY0626031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program