Healthcare Provider Details

I. General information

NPI: 1497859870
Provider Name (Legal Business Name): RAJIV NANDA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 LINCOLN ST
WORCESTER MA
01605
US

IV. Provider business mailing address

129 LINCOLN ST
WORCESTER MA
01605
US

V. Phone/Fax

Practice location:
  • Phone: 508-754-5891
  • Fax: 508-792-2029
Mailing address:
  • Phone: 508-754-5891
  • Fax: 508-792-2029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number17968
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: