MEDICARE: DR. ANIL PURSHOTAM ARDESHNA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DI01783700	NJ

General Provider Information

NPI Number	:	1427034966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANIL PURSHOTAM ARDESHNA DMD

Provider Business Mailing Address
First Line	:	110 BERGEN STREET, ROOM 712C
Second Line	:	UMDNJ-NEW JERSEY DENTAL
City	:	NEWARK
State	:	NJ
Zip	:	07103
Country	:	US
Telephone Number	:	973-972-1892
Fax Number	:	973-972-0526

Provider Business Practice Location Address
First Line	:	110 BERGEN STREET
Second Line	:	UMDNJ-NEW JERSEY DENTAL SCHOOL- ROOM
City	:	NEWARK
State	:	NJ
Zip	:	07103-2495
Country	:	US
Telephone Number	:	973-972-4729
Fax Number	:	973-972-0526

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/16/2005
Last Update Date	:	11/18/2008

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