Healthcare Provider Details

I. General information

NPI: 1063253862
Provider Name (Legal Business Name): PALAK JAYANTILAL KOTHARI DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2024
Last Update Date: 06/05/2024
Certification Date: 06/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 E DREXEL AVE
OAK CREEK WI
53154-2123
US

IV. Provider business mailing address

7971 S 6TH ST APT 119
OAK CREEK WI
53154-2011
US

V. Phone/Fax

Practice location:
  • Phone: 262-533-8387
  • Fax:
Mailing address:
  • Phone: 973-626-5038
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6001495-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: