Healthcare Provider Details

I. General information

NPI: 1457797185
Provider Name (Legal Business Name): RACHANA ASHOK HEGDE BDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 12/03/2022
Certification Date: 12/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10920 S RIVER FRONT PARKWAY COLLEGE OF DENTAL MEDICINE ROSEMAN UNIVERSITY OF HEALTH
SOUTH JORDAN UT
84095
US

IV. Provider business mailing address

11623 S ALEXANDRIA DR
SOUTH JORDAN UT
84095-5997
US

V. Phone/Fax

Practice location:
  • Phone: 840-878-1482
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9156834-ED91
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: