Healthcare Provider Details

I. General information

NPI: 1467402107
Provider Name (Legal Business Name): SURESH V VAKHARIA MDS,DDS,FAGD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3474 BROADWAY GROUND FLOOR
NEW YORK NY
10031-5603
US

IV. Provider business mailing address

3474 BROADWAY GROUND FLOOR
NEW YORK NY
10031-5603
US

V. Phone/Fax

Practice location:
  • Phone: 212-926-5692
  • Fax:
Mailing address:
  • Phone: 212-926-5692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number034568
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDI19425
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: