Healthcare Provider Details

I. General information

NPI: 1609127562
Provider Name (Legal Business Name): RAKTIM GHATAK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E NEWTON ST
BOSTON MA
02118-2308
US

IV. Provider business mailing address

100 E NEWTON ST
BOSTON MA
02118-2308
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-4046
  • Fax:
Mailing address:
  • Phone: 617-414-4046
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDL11632
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: