Healthcare Provider Details

I. General information

NPI: 1487498291
Provider Name (Legal Business Name): NIKHILESH CHANDRA ROY BDS. MDS FDSRCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 12/01/2025
Certification Date: 12/01/2025
Deactivation Date: 03/07/2025
Reactivation Date: 12/01/2025

III. Provider practice location address

12702, LAKESHORE DRIVE
GRANDE PRAIRE ALBERTA
T8X8C7
CA

IV. Provider business mailing address

45 STUART STREET APARTMENT NUMBER 2705
BOSTON MA
02116
US

V. Phone/Fax

Practice location:
  • Phone: 780-897-0742
  • Fax:
Mailing address:
  • Phone: 780-897-0742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: