Healthcare Provider Details

I. General information

NPI: 1033504840
Provider Name (Legal Business Name): VEENA KOTHAWAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2015
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 WATERSIDE PLZ APT 3F
NEW YORK NY
10010-2624
US

IV. Provider business mailing address

30 WATERSIDE PLZ APT 3F
NEW YORK NY
10010-2624
US

V. Phone/Fax

Practice location:
  • Phone: 609-815-9803
  • Fax:
Mailing address:
  • Phone: 609-815-9803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22DI02646300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: