Healthcare Provider Details

I. General information

NPI: 1235582792
Provider Name (Legal Business Name): GAURAV DESAI DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2016
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

IV. Provider business mailing address

710 FRANKLIN ST STE 200
MICHIGAN CITY IN
46360-3564
US

V. Phone/Fax

Practice location:
  • Phone: 219-872-6200
  • Fax:
Mailing address:
  • Phone: 219-872-6200
  • Fax: 219-879-2915

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019.032448
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN22075
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12013104A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: