Healthcare Provider Details

I. General information

NPI: 1124125398
Provider Name (Legal Business Name): MANRAJ S BATH DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 CROSS CREEKS BLVD
PICKERINGTON OH
43147-8237
US

IV. Provider business mailing address

1575 CROSS CREEKS BLVD
PICKERINGTON OH
43147-8237
US

V. Phone/Fax

Practice location:
  • Phone: 614-751-7500
  • Fax: 614-322-7900
Mailing address:
  • Phone: 614-751-7500
  • Fax: 614-322-7900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number20162
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: