Provider Demographics
NPI:1871564054
Name:SUJATHA H DE SILVA DDS PC
Entity type:Organization
Organization Name:SUJATHA H DE SILVA DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL
Authorized Official - Prefix:
Authorized Official - First Name:SUJATHA
Authorized Official - Middle Name:H
Authorized Official - Last Name:DE SILVA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:718-556-5432
Mailing Address - Street 1:973 TARGEE STREET
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304
Mailing Address - Country:US
Mailing Address - Phone:718-556-5432
Mailing Address - Fax:718-556-5432
Practice Address - Street 1:973 TARGEE STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304
Practice Address - Country:US
Practice Address - Phone:718-556-5432
Practice Address - Fax:718-556-5432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00946341Medicaid