Healthcare Provider Details

I. General information

NPI: 1013600717
Provider Name (Legal Business Name): KUMUDHATI TIWARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2023
Last Update Date: 05/30/2023
Certification Date: 05/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 LIVINGSTON AVE
NEW BRUNSWICK NJ
08902-1843
US

IV. Provider business mailing address

360 BERGEN AVE APT 104
KEARNY NJ
07032-3954
US

V. Phone/Fax

Practice location:
  • Phone: 173-241-8980
  • Fax:
Mailing address:
  • Phone: 302-747-0687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22DI02974100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: