Healthcare Provider Details

I. General information

NPI: 1720781438
Provider Name (Legal Business Name): PRAJKTA KHADSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 08/04/2024
Certification Date: 08/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 ALLING ST # 25
NEWARK NJ
07102-5376
US

IV. Provider business mailing address

9 ALLING ST # 25
NEWARK NJ
07102-5376
US

V. Phone/Fax

Practice location:
  • Phone: 917-415-2729
  • Fax:
Mailing address:
  • Phone: 917-415-2729
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI03054400
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: