Provider Demographics
NPI:1992251391
Name:JOSEPH, SURYA
Entity type:Individual
Prefix:
First Name:SURYA
Middle Name:
Last Name:JOSEPH
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:SURYA
Other - Middle Name:
Other - Last Name:JOSEPH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2787 NW DAYSHA DR
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-2980
Mailing Address - Country:US
Mailing Address - Phone:404-939-5152
Mailing Address - Fax:
Practice Address - Street 1:2787 NW DAYSHA DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2980
Practice Address - Country:US
Practice Address - Phone:404-939-5152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD110981223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty