Provider Demographics
NPI:1063550317
Name:SUNDARESWARAN, PUSHPA (DMD MDS)
Entity type:Individual
Prefix:
First Name:PUSHPA
Middle Name:
Last Name:SUNDARESWARAN
Suffix:
Gender:F
Credentials:DMD MDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12905 MORNINGPARK CIR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30004-7330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2880 OLD ALABAMA RD
Practice Address - Street 2:SUITE 400
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022
Practice Address - Country:US
Practice Address - Phone:678-240-2777
Practice Address - Fax:678-240-2782
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0126341223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry