Healthcare Provider Details

I. General information

NPI: 1093703936
Provider Name (Legal Business Name): JAGDISH R KOTHARI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 12/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GENESEE ST
UTICA NY
13502-5635
US

IV. Provider business mailing address

PO BOX 8078
UTICA NY
13505-8078
US

V. Phone/Fax

Practice location:
  • Phone: 315-735-7278
  • Fax:
Mailing address:
  • Phone: 315-735-7278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number034554
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: