Healthcare Provider Details

I. General information

NPI: 1306289772
Provider Name (Legal Business Name): ABHINAV P WADKAR B.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2013
Last Update Date: 04/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BERGEN ST ROOM D-830
NEWARK NJ
07103-2495
US

IV. Provider business mailing address

214 MATTHEWS DR
NEWARK NJ
07103-3152
US

V. Phone/Fax

Practice location:
  • Phone: 973-972-4615
  • Fax:
Mailing address:
  • Phone: 973-710-6147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberA-17272
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: