Sara Supriyatno, DDS

Primary specialty

Student in an Organized Health Care Education/Training ProgramTaxonomy code 390200000X

Practice address

909 Walnut St RM 300
Philadelphia, PA 19107-5211

Phone

(215) 503-7118

Fax

(215) 923-9189

NPI assigned

May 17, 2022

Last updated

Jan 9, 2024By the provider in NPPES

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in PA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1652745600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1704758400000",
    "number": "1225775778",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "909 WALNUT ST RM 300",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075211",
            "telephone_number": "215-503-7118",
            "fax_number": "215-923-9189"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "909 WALNUT ST RM 300",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191075211",
            "telephone_number": "215-503-7118",
            "fax_number": "215-923-9189"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUPRIYATNO",
        "first_name": "SARA",
        "credential": "DDS",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-05-17",
        "last_updated": "2024-01-09",
        "certification_date": "2024-01-09",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "PA",
            "license": "DS043687",
            "primary": false
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Supportive Home Care Services LLC
• Supportive Older Women's Network (Connectedly)
• Supportive Transpotation of Philadelphia Inc.
• Supports Your Way LLC
• Supreme Healthcare LLC
• Pradeep Kumar Sure
• Annu Reeba Suresh
• Shriya Suresh
• Thambipillai Sureshkumar, M.D.
• Alexandra Leigh Surget, MD

• Student in an Organized Health Care Education/Training Program in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Student in an Organized Health Care Education/Training Program in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 9, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.