Provider Demographics
NPI:1063724805
Name:VEGESANA, SURESH KUMAR VARMA (DDS)
Entity type:Individual
Prefix:DR
First Name:SURESH
Middle Name:KUMAR VARMA
Last Name:VEGESANA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4512 PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46825-5836
Mailing Address - Country:US
Mailing Address - Phone:260-399-1333
Mailing Address - Fax:260-755-3271
Practice Address - Street 1:4512 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-5836
Practice Address - Country:US
Practice Address - Phone:260-399-1333
Practice Address - Fax:260-755-3271
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028411122300000X
IN12012081A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist