Provider Demographics
NPI:1447857024
Name:SUDHEER J. SURPURE, MD, DDS, INC.
Entity type:Organization
Organization Name:SUDHEER J. SURPURE, MD, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUDHEER
Authorized Official - Middle Name:J
Authorized Official - Last Name:SURPURE
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DDS
Authorized Official - Phone:615-480-5534
Mailing Address - Street 1:1620 E CASTLE HILLS DR
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86005-2725
Mailing Address - Country:US
Mailing Address - Phone:615-480-5534
Mailing Address - Fax:
Practice Address - Street 1:GRAND CANYON ORAL AND FACIAL SURGERY
Practice Address - Street 2:1600 W. SUNSET ROAD, SUITE B
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014
Practice Address - Country:US
Practice Address - Phone:615-480-5534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1578942488OtherNPI