Individual
DR. SUTHANYA SRISURO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
D.D.S., M.S.
Contact information
Practice address
3011 GODFREY RD, GODFREY, IL 62035-1808
(618) 466-7966
Mailing address
1616 FRONTENAC WOODS CT, SAINT LOUIS, MO 63131-3428
(314) 569-2225
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
21000857
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1003841
—
IL
01
—
227188
CIGNA HMO
IL
01
—
UNITED CONCORDIA
PPO NETWORK
IL
Enumeration date
04/13/2007
Last updated
07/09/2007
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