Healthcare Provider Details

I. General information

NPI: 1427279066
Provider Name (Legal Business Name): SUNIL WADHWA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W 168TH STREET P & S BOX 20, VC9-219
NEW YORK NY
10032
US

IV. Provider business mailing address

630 W 168TH STREET P & S BOX 20, VC9-219
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-2425
  • Fax: 212-305-4609
Mailing address:
  • Phone: 212-305-2425
  • Fax: 212-305-4609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number055424
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: