Healthcare Provider Details

I. General information

NPI: 1396511440
Provider Name (Legal Business Name): PUVIN MITHRA RODRIKS BDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2023
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 OLD NORTH RD
WORTHINGTON MA
01098-9708
US

IV. Provider business mailing address

77 HOSPITAL AVE STE 102
NORTH ADAMS MA
01247-2538
US

V. Phone/Fax

Practice location:
  • Phone: 413-238-5511
  • Fax:
Mailing address:
  • Phone: 413-346-4242
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL15977
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDL15977
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: