=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124359328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AADARSH GOPALAKRISHNA D.D.S., M.S.,
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2010
-----------------------------------------------------
Last Update Date | 02/09/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 263 FARMINGTON AVE RECONSTRUCTIVE SCIENCES
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-679-8027
-----------------------------------------------------
Fax | 860-679-1370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 263 FARMINGTON AVE RECONSTRUCTIVE SCIENCES
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06032-1956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-679-8027
-----------------------------------------------------
Fax | 860-679-1370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 010167
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 010167
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------