Provider Demographics
NPI:1306530415
Name:SASI PRAKASH, SRUTHI
Entity type:Individual
Prefix:
First Name:SRUTHI
Middle Name:
Last Name:SASI PRAKASH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 WILLIAMSBURG STATION LN APT 106
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-7819
Mailing Address - Country:US
Mailing Address - Phone:440-753-1116
Mailing Address - Fax:
Practice Address - Street 1:2459 W JONATHAN MOORE PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-9206
Practice Address - Country:US
Practice Address - Phone:812-516-5777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-05
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13254122300000X
IN12014264A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist