Provider Demographics
NPI:1235758988
Name:SURESH, DIVYA
Entity type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:SURESH
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 1:415 WALLACE ST APT 2E
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-2298
Mailing Address - Country:US
Mailing Address - Phone:757-375-6116
Mailing Address - Fax:
Practice Address - Street 1:PLYMOUTH MEETING FAMILY DENTAL
Practice Address - Street 2:350 E GERMANTOWN PIKE
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19401
Practice Address - Country:US
Practice Address - Phone:610-828-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-13
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PADS0439961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program