Healthcare Provider Details

I. General information

NPI: 1053477117
Provider Name (Legal Business Name): DEEPAK H BAKHRU DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1312 SARATOGA RD
GANSEVOORT NY
12831-1561
US

IV. Provider business mailing address

1312 SARATOGA RD
GANSEVOORT NY
12831-1561
US

V. Phone/Fax

Practice location:
  • Phone: 518-798-2222
  • Fax:
Mailing address:
  • Phone: 518-798-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number034955
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: