Healthcare Provider Details

I. General information

NPI: 1871801795
Provider Name (Legal Business Name): ANKIT BAVARIYA MDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 07/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15921 BOUNDARY DR
ASHLAND MS
38603
US

IV. Provider business mailing address

15921 BOUNDARY DR
ASHLAND MS
38603-7740
US

V. Phone/Fax

Practice location:
  • Phone: 662-224-8951
  • Fax:
Mailing address:
  • Phone: 662-224-8951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3722-13
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3722-13
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: