Provider Demographics
NPI:1104318500
Name:SURTI, GOPI (DMD)
Entity type:Individual
Prefix:DR
First Name:GOPI
Middle Name:
Last Name:SURTI
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 SANDRA DR
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-8231
Mailing Address - Country:US
Mailing Address - Phone:860-803-6385
Mailing Address - Fax:
Practice Address - Street 1:725 RIVER RD STE 204A
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:07020-1149
Practice Address - Country:US
Practice Address - Phone:201-228-9567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ22DI027980001223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program