=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356897607
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SUNNY THAKKAR DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2016
-----------------------------------------------------
Last Update Date | 08/28/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 S CHRISTOPHER COLUMBUS BLVD UNIT 609
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147-3506
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-398-0110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 717 S CHRISTOPHER COLUMBUS BLVD UNIT 609
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-398-0110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DS040877
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------