Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 17979 | NJ |
NPI | 1003824913 |
---|---|
Provider Name | Sudhaker Rao Balmuri |
First Address | East Orange, NJ 07017 |
Second Address | East Orange, NJ 07017 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/08/2006 |
Last Update Date | 04/06/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1194996645 | 444 WILLIAMS ST (01) | NJ |
1740345693 | 741 BROADWAY (01) | NJ |
1932370483 | 101 LUDLOW (01) | NJ |
1972778413 | IRVINGTON (01) | NJ |
6130801 | (05) | NJ |