=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366503211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BHARGAVA DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1230 N BROADMOOR AVE STE # 300
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-3891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-630-0002
-----------------------------------------------------
Fax | 316-630-0004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1230 N BROADMOOR AVE STE # 300
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-3891
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-630-0002
-----------------------------------------------------
Fax | 316-630-0004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NEIL BHARGAVA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 316-630-0002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60181
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60182
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------