Healthcare Provider Details

I. General information

NPI: 1538268255
Provider Name (Legal Business Name): RAHUL DATAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 06/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

191 SOCIAL ST
WOONSOCKET RI
02895-3240
US

IV. Provider business mailing address

191 SOCIAL STREET THUNDERMIST HEALTH CENTER
WOONSOCKET RI
02895-0000
US

V. Phone/Fax

Practice location:
  • Phone: 401-767-4100
  • Fax: 401-767-4165
Mailing address:
  • Phone: 617-669-3580
  • Fax: 401-235-6899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN03072
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4241
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: