Healthcare Provider Details

I. General information

NPI: 1164049458
Provider Name (Legal Business Name): DIVAKAR SHESHAGIRIRAO KARANTH HUTTINAGADDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 07/02/2020
Certification Date: 07/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1395 CENTER DR
GAINESVILLE FL
32610-3006
US

IV. Provider business mailing address

300 ALUMNI DR APT 242
LEXINGTON KY
40503-1649
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5785
  • Fax:
Mailing address:
  • Phone: 415-988-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9837
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: